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THE

QUESTION OF REST

FOR

WOMEN DURING MENSTRUATION

• • •

MARY PUTNAM J,\COBI, M.D.

PROFESSOR OF MATERIA MEDICA IN THE WOMAN'S MEDICAL COLLEGE, NEW YORK

THE BOYLSTON PRIZE ESSAY OF HARVARD UNIVERSITY

FOR 1876.

ffiANC\ft^

G. P.

illvstrJlt:^ R C P E ^ ■'■ ^

x^^-^

NEW YORK
PUTNAM'S

182 Fifth Avenue

1877.

Lis

SONS

• • •

• •

• ••
• •

• ••

C '.OFVRIGHT

BY G. P. PUTNAM'S SONS

1877-

INTRODUCTORY NOTE.

THE writer of the present essay feels the necessity of
craving indulgence for many imperfections, due, in

part at least, to the necessity of completing it within a given
time, whether or no the necessary material had been accu-
mulated. This difficulty is inherent in all competitions for
prizes, awarded at a fixed date. It was somewhat increased
in the present case, from the fact that the work was only
begun one year before the date for conferring the prize, in-
stead of two years, as intended by the committee.

The author desires to express her great obligations to Dr.
Victoria White, and Dr. Mar>' Baldwin, and other ladies
connected with the N. Y. Infirmary, for their great assistance
in preparing the tables of urea analyses. A large number of
these analyses were made entirely by Dr. White.

The writer also seizes this opportunity to thank very
warmly the ladies, many of them perfect strangers to her,
who have exerted themselves in procuring the statistics
upon which the first part of this essay is based.

no ircst Thirty-Fourth Street, New York, April, 1877.

CONTENTS.

SECTION I.

PACK

Introductory— Historical— General Considerations in

regard to labor i

SECTION II.
Statistics 26

SECTION III.
Theory OF Menstruation • 64

SECTION IV.
♦ Experimental 115

SECTION V.
Theory of Supplemental Nutrition 168

SECTION VI.
Application 192

Conclusions 223

DO WOMEN REQUIRE MENTAL AND
BODILY REST DURING MENSTRUATION?

(BOYLSTON PRIZE ESSAY, 1876.)

SECTION I.

INTRODUCTORY.— HISTORICAL.— GENERAL CONSIDERATIONS

IN REGARD TO LABOR.

AN inquiry into the limits of human nature is always le-
gitimate, and often exceedingly useful. When honestly
made, it tends to increase real force while dissipating illusions
concerning imaginary powers. Thus knowledge of the limits
of muscular strength stimulates the invention of machines
many times man power. Compressed by the admitted limits
of religious thought * religious speculation is forced into more
definite channels, and assumes tasks at once more robust and
more profitable than those, only apparently more splendid,
which had hitherto absorbed its energies. When arbitrary
attempts to modify the social organism are rebutted by the un-
suspected limits imposed by its laws, resources as unsuspected
are revealed to those who choose to look for them. Such in-
deed is the audacity of the human intellect, that the discovery
of limits usually proves hopeless in only one case, namely,
when they are perceived to apply to a different race, class, or
sex, from that to which the investigator himself belongs. An
inquiry into the limits to activity and attainments that may be
imposed by sex, is very frequently carried on in the same spirit

* See Mansel. Limits of Religious Thought.

2 THE QUESTION OF REST FOR WOMEN.

as that which hastens to ascribe to permanent differences in
race all the peculiarities of a class, and this because the sex that
issupposed to be limiting in its nature, is nearly always differ-
ent from that of the person conducting the inquiry. It is true
that men have inquired with great research into the influence
exerted upon the general organization of man by the special
character and working of his sexual organization, but it is rare
that this influence has been regarded as ** limiting *' in its
nature. Moralists and theologians have pointed out the nar-
row limits into which its undue ascendancy might reduce the
rest of the physical and mental life, but their exhortations have
always assumed that such undue ascendancy would never
be attained except by wilful negligence or moral sin. Phys-
iologists and physicians again, while demonstrating the slavery
that results from abuse of the sexual functions, have hinted
of no danger consequent upon their normal exercise. On the
contrary their stimulating effects upon the rest of the economy
have been portrayed in brilliant colors by even sober pens.
To the reproductive apparatus is generally ascribed a perma-
nent influence upon the organism of whose maximum devel-
opment it constitutes the most elaborate expression. The
development and activity of this apparatus, by means of
which the life of the individual is linked to that of the race,
are said to be correlative with the development and activity
of the organs of individual life, and not in inverse proportion
to them. It may indeed be considered as quite a modern
eccentricity to claim as an element of superiority in man,
that, in the intervals of the voluntary exercise of sexual
functions, ** he is practically unsexed.** * Were the assertion
true, which it is far from being, it would prove a marked
inferiority on his part to organisms whose sexual characters
are permanent, since both in plants and animals, sexual
organisms rank higher than asexual ; the development of sex
marks a progress from the primitively neutral condition of

* Ely Vande Walker, Popular Science Monthly, July, 1875.

SEX AS A LIMITATION. 3

young animals, and privation of the organs of sex is liable to
seriously deteriorate some of the robust organs of individual
life. All this is generally recognized in regard to the mascu-
line sex. But as soon as there is question of the other, the
fundamental conception of the subject seems to be changed.
Not alone the accidents of sex or the abnormal exercise of its
functions, but the sex itself seems to be regarded as a patho-
logical fact, constantly detracting from the sum total of
health, and of healthful activities. ** Woman, in the interest
of the race has been endowed with a set of organs peculiar to
herself, whose complexity, delicacy, sympathies and force,
are among the marvels of creation,' (Sex in Education, p. 83).
Comty, (Traits des maladies des femmes, p. 274), enumer-
ates the natural phenomena of menstruation, copulation, ges-
tation, parturition, among the causes of the frequency of
uterine disease." Dr. Guerin (Movement medical quoted
by Mund^ Journal Obstetrics, Aug., 1875), says, " There is no
physiological condition so nearly resembling disease as that
which produces every month in an adult woman a change so
profound that it has been looked upon as the expression of a
morbid condition." Tilt, who declares that diseases of men-
struation have been the engrossing study of his life, defines
this process to be a " sero sanguinolent secretion " propelled
by an ovarian influence from all or different parts of the gen-
erative intestine, and principally from the womb. It is a
natural function peculiar to women. . . . who are sub-
ject to this 7iaturali?ijir7nity iov dbout seven out of the thirty
years of reproductive life.* Hutchins, in a prize essay ac-

* It is true the author adds, "If properly nurtured and cared for, they, (these
organs) arc a source of strength and power to her," and disclaims that any organ
or function in plant, animal, or human kind can properly be regarded as a disa-
bility or source of weakness.

' It is menstruation that is generally considered the peculiarity of the sex, which
most seriously cripples the individual energies of woman, since it alone exerts its
influence upon alt, and at all times during adult life.

*On Diseases of Menstruation, 1851, p. 23.

4 THE QUESTION OF REST FOR WOMEN.

cepted by a State Medical Association, says, * ** Woman has a
sum total of nervous force equivalent to a man's, but this is
distributed over a greater multiplicity of organs and directed
to the development and support of special reproductive
energies in addition to those of individual nutrition. The
nervous force is therefore weakened in each organ, — and
the period of resistance of each organ is weakened, —
it is more sensitive, more liable to derangement.' In another
place the author quotes an experiment of Rabuteau, as a
proof that during menstruation the general nutrition of the
body is diminished.* Hirt calls menstruation a condition
which, if not precisely morbid, is still often upon the limits
of pathology, and under all circumstances determines a
greater predisposition to different diseases.** * The author cal-
culated that ** every four weeks the uterus becomes hyperae-
miated in such manner that almost the entire organism is
involved in sympathetic suffering; and this during three to
five days every month, or one to two months out of every
year.** Thus even for the non-pregnant woman, " a great
portion of the time during the period of maturity is passed
under the influence of the genital sphere.** * Storer, in his
essay on criminal abortion, appends a note to the paragraph
devoted to female physicians, considered as a special class of
accomplices to this crime (p. 98), in which he remarks that,
** granting that women in exceptional cases may have all
the courage, tact, ability, pecuniary means, education, and

* Transactions New York State Medical Association, 1875.

* The inference that women arc more liable to contract diseases at the men-
strual period bears so directly upon the subject of this essay tliat it will be dis-
cussed in full further on. It is vigorously contradicted by Herard.

' We shall have occasion to refer again to this experiment, and to discuss it
in view of others made to control it.

* Die Gewerbeliche Thatigkeit der Frauen, 1873.

* We shall see, however, that practically, Hirt thinks that no modifications
of the industrial work of women, based upon the existence of menstruation, are
either desirable or practicable.

MORBID EFFECTS OF MENSTRUATION. 5

patience necessary to fit persons for the cares and responsi-
bilities of professional life, they still are and must be subject
tx) the periodical infirmity of their sex ; which for the time,
and in every case, however unattended by physical sufferings
unfits them for any responsible effort of mind, and in many
cases of body also. It is not to women as physicians we
would object ; . . . but to their often infirmity^ during
which neither life nor limb submitted to them would be as
safe as at other times. We could hardly allow to a female
physician (?) convicted of criminal abortion, the plea that the
act was committed during the temporary insajtity of her
menstruation ; and yet at such times a woman is undoubtedly
more prone than men to commit any unusual or outrageous
act." * In the same sense Dr. Tilt, in an address to the
Obstetrical Society of London for 1874, congratulated the
members upon their almost unanimous decision that women
were not admissible, — " for the profession felt that the ver-
dict really meant that women ' were not qualified by nature
to make good midwifery practitioners ; that they were unfit
to bear the physical fatigues and mental anxieties of obstet-
rical practice, at menstrual periods^ during pregnancy and
puerperality ; and that it was unfair to society to encourage
women to suppose they could fit themselves to assume re-
sponsibilities in those formidable obstetric emergencies which
too often completely paralyze even men of experience.***
Already, in 1805, Roussel* had declared menstruation to be

* Criminal Abortion, p. loi. Boston. 1868.

* /. ^., in the opinion of the Society.

* British Med. Jour., Jan. 16, 1875. It is interesting to find in the same
volume of this journal, an editorial commenting upon a local epidemic of puer-
peral fever that had been caused by the ignorance of a midwife, and concluding
with these words: "Every day (he fact presents itself 7uith ificreasing importunity
and sometimes hideous vividness, that midwives must be improved or abolished.
The latter plan is undesirable and impossible, the former is practicable, urgently
demanded, and, to our shame be it written, has been adopted in ei'ery European country
but Great Britain''* * Syst^me Morale el Physique de la Femrae, p. 100.

6 THE QUESTION OF REST FOR WOMEN.

a salutary crisis intended to relieve a pathological condition,
induced by the excesses at table common in advanced civil-
izations ; and Auber * attributed the phenomena to the
unnatural restraint imposed by these same civilizations upon
the sexual instinct [see Beigel]. According to Hageivisch,
menstruation is an hereditary disease, developed by civiliza-
tion, and according to Moscati, by the upright position of
the human female.' A modification of the doctrines of the
Roussel school has been recently advanced by King, of
Washington, who is apparently unacquainted with the argu-
ments of his predecessors. He asserts that menstruation,
far from affording relief to pathological conditions, itself con-
stitutes a morbid state fraught with danger, inasmuch as it
is proof of functional inactivity on the part of the uterus,
which becomes therefore liable to atrophy by sclerosis.* It
is the function of the uterus to bear the product of concep-
tion, but, impregnation not taking place, involution occurs
in the membrane by fatty degeneration just as it does in the
muscular walls of the womb after delivery, with this differ-
ence, that it is at the beginning instead of the end of the
normal function, and before the mucous membrane has at all
accomplished the office for which it had been so highly
developed.*' Thus, as has been said, a woman menstruates,
only because she does not conceive.'* To Dr. King this
remark is not merely the statement of an obvious physio-
logical sequence, as when it is said that a man sleeps because
he is not awake, or fasts because not employed in digestion.
But he infers that since gestation is the proper function of
the adult uterus, in the absence of gestation, /. r., in the
presence of menstruation, the uterus is threatened with the
atrophy incurred by all organs whose functions are unnat-

* Quoted by Raciborski, Traite de la Menstniation, p. iS.

' Quoted and combated by Burdach— Die Phy^iologie Erste Band. p. 249.

1835.

• Am. Journ. Obst. August and Nov. 1875.

MORBID EFFECTS OF MENSTRUATION. ^

urally suspended. '* Nature will not support the nutrition
of a useless organ ; in the physiological offices of the system
she will allow no sinecures ; hence we always find that organs
performing no useful purpose become prone to disease, de-
generation, and decay/* As a practical inference. Dr. King
recommends that girls be encouraged to marry immediately
upon arriving at the age of puberty, so that menstruation
may be at once interrupted by a pregnancy which should be
repeated so frequently as to entirely exclude its pathological
substitute from the existence of the woman. This view of
menstruation as a pathological process grafted upon the
female economy by a progressively deteriorating civilization,
is in striking contrast with the opinions that prevailed
throughout antiquity, the middle ages, and even, until
recently, in modern times. According to these elder ideas,
women are naturally plethoric, in order to be able at the
proper time to utilize their excess of blood for the develop-
ment of the foetus.* Aristotle, to whom Raciborski attri-
butes the first enunciation of this theory, calls the men-
strual blood the marble, the sperm the sculptor, the foetus
the statue.* The Hindoo Susruta writing thirteen or four-
teen hundred years before the Christian era, also explains
fecundation by the admixture of the semen with the men-
strual blood, in which latter is contained the germ of the
embryo.*

The plethoric theory of menstruation was based ; first upon
the general analogy of the menstrual flux with other evacua-
tions; and second upon its relations to pregnancy, of which the
most superficial observation showed it to be the substitute.
The sense of discomfort or even experience of danger attendant
on suppression of the evacuations of faeces or urine, offered a
basis of sensation, upon which was easily built the theory,

• Raciborski, loc. cit., p. 8.

• Quoted by Flourens, Cours d'Embryologie.

• Quoted by Kreiger, Die Menstruation, 1869.

8 PLETHORIC THEORY OF MENSTRUATION.

that all spontaneous evacuations implied the existence of
some morbific material whose retention was extremely perilous
to the economy. The menstrual " purgation " was included
in the generalization. "The opinion, observes Kreiger,
that the body was purified by the flux from the uterus,
became permanent, and was asserted still more emphatically
in the Commentaries on Hippocrates in the sixteenth
and seventeenth centuries. So for instance, Bapt. More-
tarus, de uterin affectionibus, p. 221.** *' The uterus is the
sewer of all the excrements existing in the body ; for all
decrements flow to the uterus." ' On the other hand, the
enormous amount of nutritive material required for the devel-
opment of the foetus was supposed to be derived from some
reserve habitually not utilized for individual nutrition ; this
reserve could be none other than the blood thrown away
as superfluous during non-pregnant states, but retained as soon
as the embryo began to develop. If women escaped anni-
hilation during pregnancy, it could only be in virtue of a
plethora existing in all other conditions. Hippocrates gives
an ingenious explanation of the cause of this plethora, not
accepting as sufficient the teleological statement of its utility.
** The woman," he says, ** has a flesh more loose and soft (in
texture) than the man, and which therefore absorbs from the
abdomen (nourishing) fluids more rapidly and in greater
abundance than the masculine body. With this laxity, when
the body is (stuffed) full of blood, the tissues become hot and
plethoric, and if no evacuation is effected, a state of suffering
supervenes. The blood of the woman is warmer, and this is
why she herself is warmer than the man.' If, however, the
plenitude is evacuated (in due time) neither heat nor suffer-
ing is produced. The body of the man, on the other hand,
not being soft (and relaxed) is not susceptible of such vascu-
lar plenitude, and he is not therefore liable to an excess of
heat as a consequence of plethora. Besides, as he exercises

' Kreiger. Loc. cit. p. 5. ' This is also asserted by Loiigct.

PLETHORIC THEORY OF MENSTRUATION. 9

more than the woman, a part of the (nutritive) fluid is dissi-
pated by fatigue.** *

Sanctorius believed that a monthly plethora occurred
in both men and women, each of whom increased period-
ically in weight to the amount of one or two pounds.*' '

Boerhaave explains the plethora of women in a different
manner. ** About the time,'* he says, " that the body of a
female is arrived at its full growth, it uses to make a greater
quantity of blood, than what the vessels will contain, which
is the reason why part of it is let out at the end of the arte-
ries of the womb, which evacuation is called the monthly
courses. If the blood is retained then follows a plethora.** *
The correlation between the cessation of growth, and the
establishment of the menstrual flow that is presumed to
represent the nutritive material become excessive for the
needs of the body, is insisted upon at greater length by
Haller. " At the age of thirteen, at the same time that the
semen begins to form in the male, the whole mass of blood
circulates with increased force. At this time when the
growth of the body begins considerably to diminish, and the
blood, finding easy admittance to completed viscera, is pre-
pared in greater quantity, a plethora frequently (?) follows.
In the male this is frequently vented by the nose. In the
female a more easy vent is found downwards. The uterine
vessels are enlarged, of a soft fleecy fabric, seated in a loose
hollow part, with a great deal of cellular fabric interspersed,
very yielding and succulent. For these causes the vessels
being more easily distensible, the blood finds a more easy
passage into the cavity of the uterus than into any other part.
— Again, the return of blood is more slow, both because of the
flexures of the arteries which become serpentine, and retard

* Oeuvres d'Hippocrate Traduction Littre Trait^ des maladies des femmes,

p. 13.

'Aphorism LXV., 1770.

•Aphorisms, 1290 and 1291. Translation from Latin. 1728.

lO THE QUESTION OF REST FOR WOMEN.

the blood motion, and also because it passes with more diffi-
culty through the veins. The blood, therefore, first collects
in the vessels of the uterus, then accumulates in the arteries
of the loins, and the aorta itself, which, urging on a new tor-
rent of blood augments in force so far as to discharge the red
blood into the serous vessels/ The quantity of the menstrual
flux is promoted by everything that either increases the
quantity or the momentum of the blood more particularly
to the uterus, such as joy, lust, rich diet, warm air, lively
temperament/* '

Burdach* (1835) remarks that "as menstruation offers
local and general phenomena, so it depends upon local and
general causes. The general cause is evidently, that in the
female body the formation of blood is sufficiently* rich to
provide every four weeks for an overflow of the same — whose
evacuation becomes a necessity. For after this evacuation is
there complete health and regularity of all forces, and the
body has the same weight as before. The menstruation is
richer when the formation of blood is abundant, and weaker
when blood is deficient, from insufficient foods, tedious
disease, etc. We believe this excess of blood depends upon
an excess of formative power in the woman, and that the
menstruation, in its increase and decrease, stands in exact
proportion to the formative activity, and also to its expend-
iture. For where matter and force are employed for the
movement and nutrition of the muscles, the plastic force can
develop itself less in other directions ; when on the contrary
the muscular power is less exercised, then developes easily a
C upp'S^' ) formation of fluid material. The menstruation is
more profuse in weakness than in vigorous health, in towns-

* This partly foreshadows Rougct's theory of the erectile accumulation of
blood in the pelvic blood vessels, on account of the serpentine flexures of the ar-
teries, and of hindrance to the reflux through the veins.

' Haller Elements of Physiology, 1786. (English Translation, vol. 2, p. 183.)

' Loc. cit., p. 241,

SOURCES OF THE MENSTRUAL BLOOD. II

women than in peasants. The local cause of menstruation is
the specific direction of the plastic force to the organs of
generation. On account of their high vitality, menstruation
may exist even in the absence of any general abundance
of blood." Wagner (Handworterbuch, Bd. 4. p. 879. 1853),
after accepting the ovular theory of menstruation, unknown
to Burdach, says : ** The blood that is evacuated at the time
of menstruation contains all the constituents of normal
blood, and is a part of the blood which circulated in the
body. It is an excess which is acquired in the {^ Getriebe')
of the individual life, whose formation is rendered possible
through the entire mechanical disposition {anlage) of the
body. It is completely analogous to the formative material
elsewhere employed for the development of the embryo.
The menstrual flow ceases during pregnancy. The excess,
which at other times may be eliminated without danger to
the individual life, which indeed must be eliminated, under
pain of multiple disturbances, now serves to cover the in-
creased expenditure." * " The evacuation of the menstrual
blood is nothing else than the elimination, under a special
form, of superfluous productive material." The author, who
considers the slight hemorrhages accompanying the rut in
some of the higher mammalia to be completely analogous to
menstruation, observes that this evacuation is confined to
mammalian animals because in them the ovum is so small as
to make only the most insignificant demand upon the plastic
force, and this therefore remains in excess. Astruc declared
that the blood and lymph destined for the nutrition of the
foetus is derived from that which, previous to puberty, had
been used for growth, and during the maturity of the woman
continually accumulates in certain veins on the inner surface

* Wagner endeavors to show that the weight of menstrual blood saved during
ten months gestation exactly equals the weight of the foetus at term. But by the
utmost stretching this can only be found by admitting that ten ounces of blood
are lost at each menstruation, which is evidently too much.

12 THE QUESTION OF REST FOR WOMEN.

of the uterus. When these are swollen by the accumulation,
they protrude into the uterine cavity, are called " coecal
appendages,'* and from them flows the blood at menstruation.
Allan Thompson, writing about the same time as Burdach,'
says menstruation is to be regarded as the means for relieving
the female system from an overplus of blood, which exists
during the whole time that it is capable of propagation. It
is to be regarded as indicating a surplus, but not constituting
the whole amount required for the foetus. For as only five
or six ounces are lost at each menstrual period, only fifty
ounces or eight pounds (three pounds and two ounces avoir-
dupois) could be accumulated in the ten months of preg-
nancy, whereas the foetus weighs from six to ten pounds.
Capuron attributes the theory of plethora to Galen, and dis-
putes it. He himself explains menstruation as the result of a
general shock given to all the organism and especially to the
womb, to dispose it to conceive, to retain the germ, and to
develop it during pregnancy.

It may therefore be confidently asserted that, previ-
ous to the discoveries which associated menstruation
with the dehiscence of ova, this peculiar phenomena was
almost universally regarded as a proof of an excess of nutri-
tive force in the sex upon whom devolved the greatest cost
of reproduction. From Hippocrates to Burdach (see ut
supra), this presumed excess of nutritive force in women is
constantly contrasted with their deficiency of muscular force
as compared with that of man, and with the arrest of the
growth which is continuous in children. Menstruation in
women, muscular force in man, growth in children, were held
to be more or less exact equivalents to one another.' But
in 1845, ^^'it^ ^^^ establishment of the fact of spontaneous
ovulation, the conditions of general nutrition upon which

* Todd's Cyclopedia, Art. Generation. 1836.

• Thoui^h Hermann considers the menstrual fluid to be the exact equivalent —
in plastic force— of the sperm.

PERIODICITY OF MENSTRUATION. 1 3

menstruation could be supposed to depend began to be lost
sight of in comparison with the remarkable local phenomena
with which they were asserted to be exclusively associated.
The congestion of the ovary, ripening of the ovule, effusion
of the serum and blood into the Graafian follicle ; its rupture ;
the escape of the reproductive cell ; its seizure by the fimbriae
of the Fallopian tube ; its journey along the oviduct and
descent into the uterus ; the hyperannia of the latter, the
turgesence of its mucous membrane, the rupture of its blood
vessels, and local hemorrhage ; this entire succession of pro-
cesses seemed the more surprising because more recently
demonstrated, and to cause a greater perturbation of the
economy, because occurring at intervals. For the first time
the periodicity of menstruation began to be considered as a
morbid circumstance. Although physiologists pointed out
that the periodicity of menstruation belonged to the general
law of vital phenomena/ as earlier rude observations had
associated it with the periodicity of cosmic phenomena,'
clincians came gradually to look upon it as a fact which
isolated menstruation from all other physiological processes,
which rendered its ordinary course dangerous, its derange-
ments fatal, and itself was sufficient to make any utero-
ovarian disease baffle the skill of the physician. Aran, who
disputes the ovular theory of menstruation, saw in the
periodical return of uterine "congestions'* the main reason
for the desperate tenacity of uterine disease — the patient

* Dalton, Treatise on Physiology, p. 548. Beclard, Elements de la Physio-
logic, 1867. Longet, Traite de la Physiologic.

' See Mead, De imperio solis et Lunne. Danvin, Descent of Man, p. 204,
vol. II, associates it with periodical alterations of nutrition, to which were sub-
jected the primitive ascidian ancestors of the human race, from the lunar revo-
lutions of the tides. "All vital functions tend to run their course in fixed and
recurrent periods, and with tidal animals the periods would probably be lunar,
for such animals must have been left dry or covered deep with water — supplied
with copious food or stinted — during endless generations, at regular lunar
intervals."

14 THE QUESTION OF REST FOR WOMEN.

being exposed to incessant relapses at the very brink of
recovery. In the same spirit, Courty remarks that "men-
struation '* constantly intervenes to produce and aggravate
uterine disorders by fluxion, congestions, and critical evacua-
tion.* Scanzoni says that during a chronic metritis, every
menstruation offers an occasion for the development of a new
acute inflammation." Kiwisch, speaking of the desquamation
of the mucous membrane of the uterus during men-
struation, observes : ** This periodic physiological process
determines at the same time a disposition to various
anomalies of menstruation ; " * and again, " Chronic inflam-
matory affections of the uterus are almost constantly ag-
gravated at each menstrual period, or even return after
they have been removed, so that the greatest hindrance in
the treatment of many cases of metritis is the repeated men-
strual congestion." * Finally, all writers, of whom some have
been already quoted, who call menstruation an ** infirmity,"
base the epithet mainly upon the periodicity of the hemor-
rhage. " It is a constantly recurring infirmity that occupies
about seven years out of thirty of a woman's adult life." It
would seem as if for these writers, were the flux continual,
or of as frequent occurrence as defecation or micturition, the
idea of infirmity would be abolished. On the other hand,
Beigel,* writing in most recent times, and after investigations
have shown the ** periodical congestion of the uterus to be
much more extended in duration than was formerly sup-
posed," observes that " menstruation is of so much the more

* Loc. cit., p. 2S6.

' Die Chn^nische Metritis. 1867. (For a more favorable view by the same
author, see at infra.)

* Muttcrkrankheiten, Bd. I. p. 4.

* Loc. cit., p. 14. This is equivalent to saying that the greatest obstacle to
the cure of any visceral disease is the continuance of the functions of the organs
involved, which keep up hypenemia and innervation. The fact is true, but not
peculiar to uterine pathology.

* Die Krankheilen der weiblichen Geschlechtorgane.

DANGERS OF PHYSIOLOGICAL PROCESSES. Ij

significance in relation to chronic metritis because its influence
is almost unintefrupted. In the most favorable cases we can
only suppose ten to fourteen days rest, and that is not quite
certain. This continual ebb and flow of circulation of the
pelvic organs, constitutes a predisposition to the develop-
ment of most diseases of the female sexual sphere/' " At
the time of menstruation the uterus is iit a state which offers
all the conditions from which metritis developes itself." *

Thus one of the most essential apparent peculiarities of
the menstrual process, its periodicity, that formerly was sup-
posed to indicate a periodical increase in the vital forces of ,
the female organism, has come to be considered as a mark of
constantly recurring debility, a means of constantly recurring
exhaustion demanding rest as decidedly as a fracture or a
paralysis. The comparative novelty of this view is assuredly
no proof that it is erroneous. Investigations into the laws
of animal organisms, have repeatedly shown them to be far
more complex and more delicate than had been imagined by
the rough common sense of mankind. The nature and
urgency of the perils menacing the life of young children, of
puerperal women, of wounded men, have only recently been
demonstrated with sufficient clearness to attempt their
prophylaxis. The dangers have been proven to be inherent
in crowds of habitual circumstances that for centuries have
been regarded with indifference or accepted with complacency ;
air, supposed to be healthful has been proved foul ; water,
believed innocuous, has been convicted of poison ; food,
the staple support of entire populations, has been accused as
the cause of their most desolating epidemics ; or certain
articles of food considered insignificant, have been shown to
be so essential that certain diseases are specifically correlated
to their absence.* Lucrative trades have been condemned as

* The same might be said of the stomach during digestion, or the brain dur-
ing activity, i.e.s that then gastritis or meningitis seemed to be the most imminent.

* Vegetables and scurvy — Iodine and goitre.

l6 THE QUESTION OF REST FOR WOMEN.

incompatible with the health of the workmen who embraced
them in ignorance and with alacrity ; * methods of work and
hours of work, shown to be deadly in their influence over the
laborers upon whom they were imposed;* and gigantic in-
dustries are revealed as reposing upon holocausts of human
beings. Indeed it may be said, that in the need and greed of
human life, all the conditions of human existence have been
trampled upon so ruthlessly that the marvel is that it has so
often survived. It is not therefore inconsistent with what we
know of the acquirement of knowledge about the most ob-
vious physical conditions, that this special condition of
menstruation, should have been hitherto misinterpreted in
regard to its influence upon the activity of the persons sub-
jected to it. Although not yet proved, it is conceivable that
all women should require an extra rest on account of it, as
all children have been shown to require extra sleep on ac-
count of their immaturity. It is not impossible that the
organization of the industrial world without reference to this
physiological requirement, has been at least as great a hard-
ship to women, as inattention to requirements of ventilation
and drainage have proved to be to all laborers. It is scarcely
more improbable to ascribe ill health of women to neglect of
precautions in regard to this physiological process, than in
regard to the physiological process of parturition which is un-
questionably the starting point of hosts of diseases, and the
cause of death to about one woman in i8o. A line of argu-
ment not more subtle than was employed by Hahncman in
tracing insanity and consumption to suppression of scabies,
might even demonstrate that the majority of all cases of dis-
ease in the female sex, resulted from prevalent habits in
regard to the menstrual period, the minority only of individ-
uals escaping the legitimate consequences of their mode of
life, on account of some exceptional strength of -constitution

* Cutler)' — Lead — Phosphorus factories.

' On mines, (coal and quicksilver) dressmakers, factory children.

WOMEN IN INDUSTRY. 1/

But ifthcse hypotheses be true, the practical consequences
are at once so important and so inconvenient, that they
should only be accepted after the strictest scrutiny. It is
well to glance for a moment at the statistics of the work per-
formed by women in various parts of the world, without any
attempt to secure for themselves rest during the menstrual
period. Leroy Beaulieu, in his prize essay,* has shown by a
few well selected examples, that at no time and in no country
have domestic occupations absorbed the existence of the
woman in the working classes ; that this ideal society where
the man might suffice for the necessities of the family, and
the woman only be obliged to look after the house and the
education of the children, has never existed in the past ; that
whenever a branch of remunerative employment has been
open to women, they have precipitated themselves upon it
with avidity, and that in the absence of industrial pursuits,
they have fallen back upon occupations coarser and less
productive.

**The workshop existed in Europe long before the tenth
century, under the name of gynecee, sometimes attached to
the house of the lord of the manor and under the direction
of his wife, sometimes belonging to abbeys, and controlled
by a superintendent. In convents the nuns manufactured
everything needed for their own use, then for sale in the
world. Spinning and dyeing of wool occupied a large part
of their days. In the Registers of trades and merchandises
of Depping is proof that the trades corporations, contrary to
a jprevalent opinion, were arranged to include women. We
find mentioned, workwomen in silk cloths, silk spinners,
weavers of kerchiefs, embroideresses, combers of wool, silk
hatters, and many other trades, where the women were not
only admitted as aids, but might become mistresses, or even
be eligible for the dignities of the corppration. The history
of female labor in epochs nearer to us would be the history

* Le Travail des Fcmmes au xix Siecle, 1S73.
2

1 8 THE QUESTION OF REST FOR WOMEN.

of industry itself. The more civilization is developed and
refined, the more women participate in production, and this
participation, constantly greater and more active, is regarded
by women themselves as an advantage.** In 1640, a decree
of the parliament of Toulouse, on the pretext that lace
manufacture carried off too many women from domestic
occupations, forbade this work throughout the limits of its
jurisdiction. Thousands of workwomen were thus deprived
of their bread until the decree was reversed. Although the
occupations of women under the old regime were much more
numerous than is generally believed, they were nevertheless
too little for the necessities of the women. In 1789 appeared
the petition of the women of the Third Estate to the king,
in which they claimed for their sex the right of working
without (reglementary) hindrance, and even demanded that
all trades for sewing, spinning, or knitting should be handed
over exclusively to them. Thus before the new world about
to open, the first cry of the women was, not to repudiate,
but to invoke labor, not to decline and repulse the name of
workwomen, but to claim it and make of it a title of honor.** *
This in 1789. In 1851 Paris alone contained 112,189 work-
ingwomen, of whom 60,000 were employed in various kinds
of needle-work. In 1873 it may be calculated that about
400,000 or 450,000 women are employed in France in manu-
factories of cotton, wool, linen, or silk. In 1861, in Great
Britain, the textile industries occupied 467,261 women and
808,273 men, or about three women for every two men.'*
In 1864 — we continue to quote Leroy Beaulicu — in 1864 a
total of 747,261 women were engaged in the industrial estab-
lishments of Great Britain. Lord Brougham, in a speech
before the Social Science Association in 1862, affirmed that
** three-quarters of adult unmarried women, two-thirds of the
widows, and a seventh of married women, are occupied in
Great Britain on independent or isolated labors, without

* See also Richter, Recht der Frauen auf Arbeit. 1869.

WOMEN IN INDUSTRY. IQ

counting the multitude of wives, daughters, and sisters, who
share in the work of their relatives at the counter, in the
dairy, or by the needle/*

In Germany, Hirt enumerates female laborers in manu-
factories for bronzes, (Nuremberg) pins, gold leaf, glass and
porcelain, wool^ flax, tobacco, paper, straw hats, india rubber,
paints, looking-glasses, toys, phosphorus matches, sugar
refineries, colors, etc., etc. In the United States, the census
for 1870 shows that out of 9,750,000 females above ten years
old, 1,594,783 are represented on tables of occupations taking
part in the paid indifstry of the country.' This is one-sixth
of the entire female population. Among these, 373,832 are
registered as agricultural laborers, and of these the immense
majority is in the Southern States, and probably consists of
negroes, who for our purposes may be excluded from the
reckoning. This leaves 1,221,451 white women engaged in
work of sufficient regularity and importance to render the
question of monthly vacations a serious one. Of these,
22,681 are farmers and planters, mostly in the Southern
States, but amounting to 1,027 in Pennsylvania, and less in
some of the others. Professional and " personal ** occupa-
tions claim 1,066,672 out of the 1,198,270 remaining after
subtracting the agriculturists. Manufactures, 353,950, while
trade and commerce only employ 18,698.' Under the head
of personal and professional employments, domestic service
ranks much the highest in the numbers. It enrolls 867,354.
Afterwards comes the profession of teaching (84,047). The
next in order is the business of keeping boarding-houses,
which employs 7,060 women.* The only other classes at all

* The number recorded as keeping house is 7400,000, thus leaving a defi-
ciency unaccounted for, i.e, apparently without any employment, of 755,217, or
about three-quarters of a million.

* This opposition between manufacturing and commercial industry is in
direct contradiction to the theoretical estimate made by Mill, that women should
be more extensively employed in distribution than in production.

' A priori, we might have expected a much larger number under this head.

20 THE QUESTION OF REST FOR WOMEN.

numerously filled, are that of barbers and hairdressers (1,179)
and midwivcs (1,186), numbers almost equal to one another.*
Although, therefore, the number of women engaged in paid
employments is in all countries the minority, relatively to
the entire population, yet in itself the number is immense.
For to estimate the influence of steady occupation upon
female existence, we must add to those engaged at any given
time, a large proportion of the classes who do not then
appear on the tables, but are registered as married or keeping
house. A very great many of those have been occupied in
paid pursuits previous to marriage, and from the statistics of
widowhood in England and America, we know that many
are destined to return to the same at a later period of life.
Tilt has pointed out that the tables of the Registrar General
indicate late marriages and late child-bearing as much more
frequent than is generally supposed.' Since marriage and
domestic service constitute the only natural equivalent for the
paid industry of women, everything which delays marriage
tends to increase the extent to which they will engage in non-
domestic professional or industrial occupations, and the reg-
ulation of their labor becomes therefore of more importance.
In Europe very much more than in America, and on the
continent more than in Great Britain, marriage among the
laboring classes does not interrupt industrial life, since the
earnings of the woman are needed for the support of the
family. ** It is unfortunately evident,'* says M. Simon,' " that
if the average wages of a good workman are two francs a day,
and that the sum needed for the support of his family is three
francs, the best advice that can be given to the mother is to
learn a trade and earn the requisite twenty sous. This con-
clusion is inexorable, and there is neither theory, nor elo-
quence, nor sentiment, which can resist a demonstration of

* The number of women registered as physicians is between five and six hun-
dred (we forget at this moment the exact figure).

' Change of Life. 1S57. p. ig. ' L'Ouvricrc, p. 12.

INDUSTRIAL WORK OF WOMEN. 21

this kind.'* " The «: /r/^r/ character of the family organization
as derived from the unequal distribution of strength between
the man and the woman, are far from being realized in actual
life." It is impossible to exclude young girls from manu-
factures, our industry has need of the labor of woman and
women are in imperative need of the salaries afforded by
wholesale industry.** ' The preoccupations of philanthropists
like Simon, are concentrated upon the demoralization of the
family, alleged to be inevitable when the mother is at work
out of the house, though the life of the workshop or the fac-
tory is not deleterious to health, indeed both more hygienic and
more remunerative than any work which can under the present
system be carried on at home. On the other hand the at-
tention of hygienists like Hirt,' is directed almost exclusively
to the increased number of abortions and higher rate of infan-
tile mortality which is asserted to accompany the extended
employment of married women in factories. The author's sug-
gestion for legal interference to regulate female labor, bears
exclusively upon this point, and, although at the beginning
of his essay, he classes menstruation with pregnancy, parturi-
tion and lactation, in its tendency to diminish the industrial
capacity of women, yet at the close he declares impossible
and unnecessar}' any attempt to frame regulations in accord-
ance with the supposed exigencies of this physiological pro-
cess.*

From this brief glance at the actual condition of mod-
ern society, it is evident that its existing regulations are little
prepared to " yield to nature her inexorable demand for rest
during one week out of every four ** in the adult life of
women. If the answer to the question asked by the com-

* Leroy Beaulieu, Les Travail des femmes au xix siecle, 1873. I condense
the substance of several scattered remarks.

'Die Gewcrbliche Thatigkeit der Frauen, 1873.

'The quotation made by Ames (Sex in Industry) from the first page of Hirt's
Essay, conveys an impression that is not confirmed by Hirt's conclusions.

22 THE QUESTION OF REST FOR WOMEN.

mittce be in the affirmative, a revolution in industrial cus-
toms should be required at least as radical as those enforced
by the English Factory Laws of 1842. This question though
apparently simple, is in reality difficult even to ask with pre-
cision. Each term is susceptible of various shades of mean-
ing. If it be said, " It is necessary that women rest during
menstruation," we must ask necessary for what purpose ? ^
The preservation of life ? Evidently not, since the most
superficial observation shows thousands of women of all races
and ages engaged in work of various degrees of severity
without attempting to secure repose at the menstrual epoch.
But in regard to the periodical repose of sleep, it is impos-
sible even to imagine that it should be secured, at least to
some extent, even though insufficiently. It is indeed super-
fluous to assert that any condition really necessary to life,
cannot be destroyed except under penalty of death. It is,
however, conceivable that rest during menstruation may be
necessary- for the attainment of a high standard of health, or
for the avoidance of certain forms of disease. The average
amount of diurnal repose is a tolerably fixed quantity, the
limits of whose variations are known, and any marked trans-
gression of those limits is certainly followed by serious deteri-
oration of health. The injury is severe in proportion to the
immaturity of the individual, and to the length of time to which
he is exposed to the deteriorating influence. If the necessity
for menstrual rest be in any way so imperious as that for a
fixed amount of sleep, it must follow that the persons de-
prived of the one will suffer as certainly and proportionately
as those robbed of the other. Moreover it should be made
as clear in the one case as in the other that the condition
examined was alone sufficient to produce the deterioration of
health, in the absence of all the other circumstances by which
it is habitually complicated. After sifting out these circum-
stances as completely as possible, we should discover a strict
correlation, both direct and inverse, between the degree of

IMPORTANCE OF REST. 23

health attained by different classes of women, and the degree
to which they obtained the amount of menstrual rest ascer-
tained to be the necessary average. We are authorized to
expect this from the facility of establishing such a correlation
in regard to sleep, — the type of periodical repose. If the de-
gree were fixed to which menstrual rest of some kind may be
necessary in order to avoid a special predisposition to disease,
the duration of that rest would still remain to be determined.
This indeed is appreciated by the committee who have framed
the question submitted for decision. This duration might
be fixed empirically, that is by ascertaining the number of
days the women who do rest habitually claim for that pur-
pose ; or else it may be determined theoretically from con-
sideration of the succession of phenomena that constitute the
menstrual process, the length of time occupied by each, and
the presumed relations of each to the rest of the economy.
In regard to this point, a very slight investigation will dis-
close a singular discrepancy between the claims of theories'
and the habit of practice, and also between the inference
that may be derived from different theories, and especially
when these have been advanced at different states of knowl-
edge in regard to the physiology of menstruation.

But the degree of rest does not vary merely in its dura-
tion relatively to that of the menstrual epoch, but in its
intensity relatively to the occupation habitually pursued. It
might be supposed that the rest, if required at all, must
necessarily be complete, in proportion to the strenuousness
of the occupation. It is certain, however, that this is by no
means the case, either in regard to physical or to mental
strain. It has been impossible to obtain, as we had hoped,
a complete table of women engaged in various employments
that exacted unremitting attendance; and to compare the
suffering experienced by them at the menstrual epoch with
that claimed by others, whose more luxurious mode of life

24 THE QUESTION OF REST FOR WOMEN.

permitted complete repose. But some data have been pro-
cured on this point which are far from useless.

There is another point of view from which this question
of menstrual rest may be considered. If the working capacity
of women during the period of haemorrhage be really and
uniformly diminished, the work done at this time should be
expected to be inferior in quality to that performed at other
times. Since at any given time, out of any given number
of women, a certain proportion will always be found men-
struating, it is possible that the average inferiority that is
ascribed to their collective work, as compared with that of
men, may be explained by this condition peculiar to their
sex, which, although not always operative upon each indi-
vidual, is always influencing women considered en masse*
Room would then be afforded for the suggestion, that the
quality of work performed in non-menstrual, i,c, non-hemor-
rhagic periods, would be raised above the average, if an
absolute rest from work were observed at the time of the
menstrual flow; 2%d that thus the quality of women's work
would be everywhere raised to the level of that of men's.
This, indeed, is the formal proposition of Dr. Clarke in
relation both to the work of school-girls and to the industrial
and professional work of adult women. This suggestion is
plausible, and requires all the more careful scrutiny, lest if it
be not in accordance with the real facts of the case, it should
be adopted in the place of some other provision for rest
which is.

The question proposed by the committee resolves itself
into the following series of questions:

1. What proportion of women habitually suffer pain or
discomfort of any kind during any part of the menstrual
period ?

2. How many out of this proportion are compelled to
suspend their ordinary avocations on account of this pain ?

3. Is there any uniform relation between the nature of

QUESTIONS TO BE ANSWERED. 2$

the occupation and the necessity for its interruption, /. €, do
some occupations more frequently necessitate intermissions
than others ?

4. Among women who, on account of immunity from
menstrual pain, have never been in the habit of resting at
the menstrual period, are there any considerable number
whose health has progressively deteriorated without the
presence of any other condition that could be assigned as
the cause of such deterioration ?

5. What is the real succession of phenomena in the
menstrual process,^and what relation does it bear to the other
processes of the economy ?

6. This relation established, what inferences in regard
to women's capacity for work, should be theoretically deduced
from it ?

7. If discrepancies exist between the practical statistics
and theoretical inference, how are they to be explained ?

8. Finally, do either facts or theory point to any hygi-
enic rules exclusively applicable to the work of women?

SECTION II.

STATISTICS.

THE answer to this first question, if asked without dis-
tinction of age, constitution, family history or occupa-
tion, is not very difficult to obtain ; although considerable
time must often be expended upon inquij^'. The statistics
obtained by Bricrre de Boismont and frequently quoted, are
compiled from three hundred and sixty women. Of these,
two hundred and seventy-eight suffered various degrees of
colic, some very slight, at the menstrual period {jy per cent.),
while eighty-two enjoyed complete immunity. This is less
than 23 per cent. In regard to general symptoms, three
hundred and thirty-four women were questioned, replies are
given from two hundred and twenty-three; of whom 181 de-
clared that they were conscious of no change during menstru-
ation, while forty-three, about one-fifth, admitted that
menstruation was a period of suffering, especially nervous or
moral. These brute statistics have precisely the same value
as the empirical formula of a compound substance submitted
to elementary analysis. The rational formula can only be
obtained by comparing the single datum, pain or not pain,
with a variety of other circumstances. In order to do this
effectually, we have prepared the following table of questions,
each of which was to be answered by the person replying to
the one question in regard to pain.

The undersigned^ desirous of collecting reliable statistics in regard to
the menstruation of women in America^ 7c>ould feel indebted to all who
would answer accurately^ the following (Questions,

No sigtiature is necessary.

CIRCULARS. 27

1. Age of going to and of leaving school.

2. Health under 13. Specify any disease of parents or sisters.

3. Number of hours a day spent in study at school.

4. Hours spent in exercise every day during same period.

5. Studies pursued between ages 13 and leaving school.

6. Occupation (if any) since leaving school, and hours of work.

7. Health, general, since leaving school. Specify date of any illness.

Do you have headache or neuralgia ?

8. Date of first menstruation.

9. Pain at menstruation, while at school and since leaving.

10. Does pain occur before, during, or after flow.^ Spasmodic, cramp-

like, or steady and burning ?

11. Does pain exist between menstrual periods ?

12. What is duration of flow .^ Has it ever been excessive or too

scanty ?

13. Has it been necessary- to rest during period ? If so, how long.^ When

did this first become necessary ?

14. Strength, as measured by capacity for exercise. How far can you

walk ?

15. Have you ever been treated for uterine disease }

16. Are you thin or stout, rosy or pale, tall or short .^ Has any change

taken place since twenty in color, flesh, or strength ?

Although a thousand of these tables were prepared for
circulation, we have only been able to obtain up to this date
two hundred and sixty-eight answers. Out of this number,
ninety-four persons record themselves as never having suf-
fered either pain, discomfort, or weakness during the men-
strual flow. This is 35 per cent, of the whole — less than
one-half, but more than the percentage given by Brierre de
Boismont.'

The total number of cases divide themselves, therefore,
into two classes, each of which must be separately analyzed.
Of the first class (those who have not suffered pain), the fol-
lowing table presents the statistics in regard to attendance
at school :

THE qup:stion of rest for women.

> TABLE I.— SCHOOL ATTENDANCE. (Group i.)

Age at
Beg:inning.

No. Casus.

Ajjc of Leaving:.

No. Cases.

Hours of Study.

No. Cases.

2 years.

12 years.

4 hours.

3 " •

ij "

5 "

4 "

14 "

6 "

5 "

15 "

7 "

6 "

i6 "

8 ."

7 •*

17 "

10 "

8 "

i8 *•

Not specified.

9 "

19 -

lo "

20 ••

II "

21 "

12 "

22 "

14 "

23 "

Not specified.

25 "

• • • •

27 "

• • • *

30 **

• • • •

Prof. stiidie> not

• • • •

specified.

Total

This tabic shows: I. That the great majority of persons
of whom wc have been able to obtain statistics have attended
school during a number of years.

2. That school attendance begins at the age of five, six,
seven, or eight, in about the same number of persons, and
the.se collectively are 52, or 5 5 J- per cent, of the whole num-
ber (94) of whom the earliest date of attendance is .specified.

3. The age of leaving school, or rather of ceasing to
study, varies much more. The greatest number, sixteen,
leave at the age of sixteen. This is nearly 18 per cent, of
the whole number recorded (89). The next age in point of
frequency is seventeen, where the number of persons is 11, or
12 per cent. The next is nineteen, with a record of eight or
nearly nine per cent, while the ages of fifteen and eighteen
give the same number, six or nine per cent. This coinci-

^ It will be seen that the figures of totals on the tables are not always identi-
cal. This is because all. the questions asked in the circular are not answered in
each response.

ANALYSIS OF TABLE L 29

dence is probably accidental, and of no significance in the
small number of figures operated upon. But the ages, fifteen,
sixteen, seventeen, eighteen, and nineteen, represent col-
lectively the age of cessation of study for forty-seven
persons, or over 52 per cent, of the whole number speci-
fied (64).

4. The nine persons who are stated to have left school at
ages of twenty-two, and over four at twenty-two, one at
twenty-three, two at twenty-five, one at twenty-seven, one at
thirty, were all engaged in professional studies, and their
number should therefore be added to the four of which this
was specified, making a total of thirteen, or a percentage of
fourteen.

5. No average has been calculated for the number of
years passed at school or in study, for no useful purpose
would be served by it. But the persons who are represented
as beginning school early do not cease attendance any earlier
than the others. Thus of the thirteen who began to go to
school at the age of five, two left at fifteen, three at sixteen,
two at seventeen, one at eighteen, one at twenty, one at
twenty-one, one at twenty-two, one at twenty-five, and one is
not specified ; and of the nine persons who began school at
the age of two, three, or four, two went until seventeen, two
until eighteen, one until twenty, and one until twenty-four,
or two-thirds of the whole ceased at a later age than
the average, the remaining three somewhat earlier (14,
15, 16).

Early attendance at school is not to be regarded as proof
of very precocious forcing of the intelligence, for the studies
pursued are rarely stimulating, or beyond the intelligence of
American children. But the confinement of school hours
for children under nine years of age, is a circumstance of
serious moment in the hygienic history of women. Among
those for whom the age of beginning school is specified,
seventy-one began school at nine years old or under (75 per

THE QUESTION OF REST FOR WOMEN.

cent.). Of these, only one, who went to school from the age
of four to eighteen, is said to have studied only four hours
during the early childhood. Of the others, eighteen are said
to have studied five hours a day, and thirty-six six hours.
This is 51 per cent, of those recorded.

It is certain that this amount only covers the time
actually spent at the school-hours, whose sessions are habit-
ually either five hours or six. But, except for the youngest
children, this session is always supplemented by at least two
hours study out of school, and this is acknowledged by ten
persons, who record themselves as studying seven hours a
day.

Let us compare now the amount of exercise taken by the
children and young girls who sustained this amount of
sedentary confinement.

TABLE I}. EXERCISE. (Group i.)

One Hour or

one und a

half.

Two
Hours.

Three
Hours.

Four
Hours.

Five or Six
Hours-

All out of
School.

Irrepularor
Unknown.

Out of eighty-six cases in which the exercise is recorded,
forty-nine exercised two hours and over, or 57 per cent.,
while 37, or 42 per cent, exercised insufficiently or irregularly.
This is probably the case with two others who are not speci-
fied. If we include among those who exercised insufficiently,
all who exercised two hours, we have a total of 52, or 59 per
cent, instead of 42, and 34, or 38 per cent, who seem to have
had abundant exercise.

The object of the 5th question in the circular is to ascer-
tain as far as possible to what extent mental strain had ex-
isted during the period of the establishment of menstruation,
and to distinguish its influence from that of prolonged seden-

TABLE II.

tary occupation or of deficient exercise/ The studies are
therefore compared with the hours of exercise.

By the higher English branches are meant History, Rhet-
oric or Logic, Philosophy, Literature ; by Mathematics, Al-
gebra, Geometry or Trigonometry, one or all ; by natural
sciences. Botany, Chemistry or Physiology. It is probable
that in the majority of cases these latter studies at least were
extremely superficial.

From a detailed table, specifying the exact studies in each
case, we have prepared the following condensed table. The
studies grouped as " Ornamental,'* indicate the scheme of
education most common among the well-to-do classes in
cities, which includes French, sometimes German, Music and
Drawing, but excludes Latin and Mathematics. The so-
called " Higher Education,** includes these. The studies in
Natural Sciences, except in a few cases of medical students (by
no means in all of these), can scarcely be considered superior.

TABLE II. STUDIES AND EXERCISE. (Group i.)

Common Ed.

Ornamental.

Higher.

Exercise

after 13.

20 or

14 or

42 or

Common.

2 Hrs. and over

7 cases,

under,* 13.

26^

18J

551

Ornamental.

2 Hrs. and over

II cases,

under, 13.

per cent.

• Higher.

2 Hrs. and over

26 cases,

under, 16.

The table shows that of seventy-six cases specified,
twenty only studied the common English branches, and were

' These two conditions are far from identical, since abundant exercise and even
prolonged schooling are far more healthful than short school hours, but inaction
outside of them. This point will be dwelt upon later,

* I. e, under two hours.

32 THE QUESTION OF REST FOR WOMEN.

amonc:^ the first to leave school ; forty-two took a full course
of stiidies, that is as estimated by the existing standard
for girls' education, and which includes Latin and the higher
mathematics/ while fourteen took an ornamental course,
without Latin, and principally devoted to music and the
modern languages. Of the first twenty who only had a com-
mon English education, only seven exercised daily two hours
and over, thirteen under two hours, or quite indefinitely.

Of the second group of forty-two, twenty-six took suffi-
cient exercise, (2, 3, or 4 hours) sixteen insufficient, (under
2 hours.)

Of the third group of fourteen, eleven are recorded with
sufficient exercise, three with insufficient.

The proportion of these who exercised to those who did
not is in the first group, =36 per cent, to 63 per cent.

In the second, = 59 per cent, to 38 per cent.

In the third, = 78 per cent to 21 per cent.

If any conclusion could be drawn from these figures, it
would be that the ordinary ** Ornamental ** system of educa-
tion, was that found to be most compatible with important
hygienic conditions. But the fact that in the class of pain-
lessly menstruating women, only the smallest number had
pursued this system of education, is a counter-fact that much
diminishes the significance of the first.

The sixth- question is intended to ascertain the effect
upon the menstrual health of the occupation pursued after
leaving school. It was hoped that the answer^ to this ques-
tion would cover a wide range of employments, but they are
on the contrary very limited. This is owing to the great diffi-
culty of obtaining answers from women of the industrial
classes, unless during a medical consultation, when they
are of course sick, and to be excluded from a table of
healthy cases.

* From enumeration of the names of studies pursued, a false imprcs-iion would
be conveyed that these were much more arduous than in truth was the case.

TABLE III.

TABLE in.— OCCUPATIONS. (Group i.)

Married.

Social and
Housework.

Teaching.

Other employ.

Married and
Employed.

• • • •

• « • •

Literary = 3

• • • •

27, or 29I

Medicine = 8

• • • «

23, or

per cent.

Factory — 4

Clerk = I

• • • •

25 per cent.

Business = i

• • • •

9, or

Machine work = i

• • • •

8 per cent.

Servants = 3

• • • «

• • • •

Study = 34-5 = 8

• • • •

• • •

Matron = I

13 + 6=19, or

• • • •

Total, 13

20 per cent.

Among the married women it was interesting to ascertain
the number of children born. Adding to the twenty-three
married and devoted to household duties exclusively, the six
who continued teaching, literature, or medicine, after mar-
riage and childbirth, we have :

One.

Two.

Three.

Four.

Five.

Six.

Seven.

Eight.

Nine. | Ten.

;

None.

Thus twenty-one women bore children, five were child-
less ; in three cases questions not answered.

Among the twenty-one mothers the pregnancies were
nearly all favorable.

An important question is the fourteenth, regarding the'
amount of exercise of which the women are capable .who are
free from menstrual disorder. The following table shows
that by far the greatest number of persons in this class are
capable of considerable physical exertion, and even take a
good deal of exercise habitually.

TABLE IV.

Able to walk from 3 to 15 miles 63

Walk 2 miles or under. 18

THE QUESTION OF REST FOR WOMEN.

The majority of persons in the first class claim to be able
to walk five or six miles with ease at any time, and ten or
fifteen when called upon to do so, especially during summer
vacations in the country.

The percentages are respectively 79 and 21.

Having ascertained that ninety-four women out of our
total list of two hundred and fifty-two do not suffer pain or
disturbance at the menstrual period, it is necessary to learn
whether this had been avoided by the habit of resting at that
time. Also whether, in the absence of rest, but with habit-
ually normal menstruation, uterine diseases had ever occurred.
Finally, whether this class of persons had lost or gained in
health since the age of twenty. This question has no sig-
nificance for women under thirty, but, as we shall see in
analyzing the cases of disturbed menstruation, it is of much
importance at or after that age. Questions 13, 15, and 16
were framed to meet these indications. Out of the total
number of ninety answers, the following alone were other
than negative :

TABLE V.

Habit of resting.

Treated fi^r uterine
disease.

Change in health since so.

Increased slrenplh.

Diminished strength.

9, or 10 per cent.

From this table it could certainly not be inferred that the
immunity from menstrual pain was due to the habit of rest-
ing during the menstrual flow, for such habit existed in only
a small minority of the cases. Among the nine persons in
the habit of resting, the duration of the rest, and the reasons
for taking it, were ver>' various, as shown by the following
table :

TABLESS— CHOOLING SECOND CLASS.

TABLE VL

No.

Duration of rest.

Remarks.

13
62

Eirst day.
Whole week.

To avoid dyspepsia.

To avoid aggravation of chronic
dyspepsia resulting from dila-
tation of stomach.

Sometimes half a day.

Whole week.

Extremely nervous person, sub-

W- hole week.

ject to prolonged hay asthma
debility.
Anemia after diphtheria and two
confinements.

Seldom.

An hour.

88
82

First day.

Only during two years

while

suffering from ** ulceration "

of uterus.

We must now analyze one hundred and seventy-four
cases in which menstruation was painful, or presented some
anomaly in regard to quantity or regularity. We will first
compare these cases, as far as possible, with those of the first
class, in a series of tables similar to those already framed. One
hundred and seventy cases are represented on the first table.

TABLE VIL— OF ATTENDANCE AT SCHOOL OF SECOND CLASS.

Afi^e of bef^inning

No.

Age of leaving

Hours of

school.

study.

2 years.

12 years.

3 "

13 *'

4 "

14 "

• •

5 "

15 "

• •

6 "

16 "

17 "

8 "

18 "

9 "

19 "

10 "

20 "

II "

21 "

12 "

22 "

17 "

23 "

• •

24 "

• •

25 "

• •

30 "

Total

127

Totnl

126

Total

THE QUESTION OF REST FOR WOMEN.

Not specified, but very little education
Not specified, but very much study. . . ,
Special remarks

Total.

Total (43 + 127)=

170

Additional to above, with special remarks :

No. 49

103

105

143

School from 9-16, and from 15-16, then until 18. Study hours

there 9-iu.
Educated at home.

Educated at home. 3-4 hours study daily.
Complete literary and medical course.
Graduated at medical college.
Study hours vary from 4 to 12.
Interruption school between 18 and 21.
No school between 10 and 19, then for I J years.
Attended school from 13 to 17, then from 21 to 24.
Educated at home till 15, then school to 18, now till 20.

Comparing item by item this table with the correspond-
ing table in the first class we find :

1. That a large majority of the number attended school
for a number of years, spending a number of hours daily in
study, but a considerable minority, whose attendance is not
specified, received very little education ; thirty-one cases,
drawn from personal observation, have been ranked in this
way, and in the additional table for special remarks, it ap-
pears that out of the ten cases, one was educated at home,
with three to four hours daily study, one did not go to school
until fifteen, and four sustained interruptions in their studies
of several years. The proportion of persons whose schooling
has been sh'ght, is much larger therefore in the second class,
that is among those whose menstruation is painful, than in
the first where it is not painful, 170: 31 = 18 per cent.

2. Among the cases where this is specified, the age of
beginning school is as in the first table, principally between

ANALYSIS OF TABLE VIL 37

five and eight. But the proportion who begin at this epoch
is smaller than in the first class, being 74 or nearly 59 per
cent, instead of 69. The per centage to the entire number
(170) is 43. On the other hand the proportion of those who
began to go to school under five, is larger, being 27 or 21 per
cent, (15 per cent, of the whole number 170) while in the first
table it is 12, or 13 per cent. The number of persons who
first went to school at two years or over, is only 13, or less
than 12 per cent, (17 per cent, of the whole) while in the first
class it is 15, or 17 per cent.

3. The age of leaving school differs from that of the first
table. The greatest number recorded, twenty-nine, leave at
seventeen instead of sixteen. This is 22 per cent, of those
specified, nearly the same proportion as left a year younger in
the first table. But of the whole number (169) it is only 17
per cent. The next age in frequency is eighteen, when the
number is twenty-six, or 20 per cent, (18 per cent, of whole)
and fourteen persons or 1 1 per cent, do not leave till nine-
teen. The percentage of this age is thus but little over that
on the first table, and calculated on the whole number is
less, being 8 per cent. But the ages seventeen and eighteen
furnish collectively, 55 or 43 per cent, (32 per cent, of whole)
while on the first table, the same ages give only 24 per cent.
In this class therefore, the proportion of persons who leave
school late is much larger than in the first class. The ex-
cess of schooling, however, is pnly for one year, and does not
extend beyond the age of eighteen, percentage for nineteen,
being nearly identical on the two tables.

4. Only eleven persons are recorded as pursuing studies
to or beyond the age of twenty-two, a percentage of 8^
against a percentage of 16 on the first table (6 per cent, of
the whole). This comparison shows that while the duration
of primary and secondary education was more prolonged in
the second class than in the first, the proportion of what may
be presumed to be comparatively advanced studies was twice

THE QUESTION OF REST FOR WOMEN.

or nearly three times as large in the first class as in the
second.

5. The number of hours spent in study during school life
is about the same as in the first table. This was to be ex-
pected from the uniformity of the school routine to which
American girls are subjected. Forty-nine are said to have
studied six hours a day. This, however, is only 39 per cent,
of those specified, or 22 per cent, of the whole, while on the
first table this number covers 51 per cent, of those specified,
or 43 per cent, of the whole. Twenty-five persons, that is, 19
per cent, of the specified cases, or 14 per cent, of the whole,
studied less than this, the majority, (20) occupying five hours.
This proportion is sensibly the same as that of the first class,
(18 per cent, of those specified, 15 per cent, of the whole).
Forty-three persons are said to have studied seven hours and
over, of whom three claim to have thus spent from ten to
twelve hours daily. These then were among those whose
studies were continued after age of twenty-one. This pro-
portion is 33 per cent, of those specified, or 25 per cent, of
the whole. In the first class the percentages are 26 and 22,
a good deal less.

The next table shows the amount of exercise taken by
girls, in whom this was specified.

TABLE VIII. EXERCISE OF SECOND CLASS.

Half
Hour.

One
Hour.

Two
Hours.

Three
Hours.

1
Four jFive or Six
Hours. Hours.

All out of
School.

Irrcfi^ular or
Indefinite.

Out of the one hundred and sixty-nine cases, eighty, or
47 per cent, are said to have exercised two hours or over,
and eighty- nine, or nearly 50 per cent, have exercised irreg-
ularly or insufficiently. The proportions, therefore, are ex-
actly the reverse of those of the first class, which we have

ANALYSIS OF TABLE VIII. 39

found to be respectively 57 and 42 per cent, (see page 30.)
Now for children and young girls, two hours must certainly
be considered as the veiy minimum of exercise, admissible as
hygienic. In the second class, it represents much the largest
number of cases among those who can be considered to have
exercised at all, namely 29, as compared with 17, 10, 13 and
II, while in the first class the number 15, of those who exer-
cised two hours, is equalled by those who exercised four.
In the first class the percentage of persons exercising three
hours and over is 38, while in the second class it is only 30.
It is clear, therefore, that as a whole, the amount of exercise
taken during school life by persons who, at any age, became
subject to painful menstruation, is inferior to that taken by
those who, up to date, were perfectly free from menstrual in-
convenience. The absolute figures, however, 80 and 89, are
sufficiently near alike to necessitate a closer analysis. Among
the one hundred and sixty-nine cases here grouped together
as suffering from menstrual pain, the degree of suffering, the
age at which it first occurred, and the concomitant circum-
stances of general health vary considerably, and one of the
most important distinctions is to be made between the cases
where menstruation was painful from the beginning, and
those in which the habit of pain was only acquired later in
life. Among the one hundred and seventy persons, men-
struation had been more or less painful, scanty or excessive
from the beginning in 90, or 53 per cent ; while in 80, or 46 per
cent, no inconvenience was experienced, until some time after
its establishment. We will call these two classes of cases,
Groups II and IV.* In Group II, three persons are said to have
suffered exclusively during the first two years of menstruation,
which coincided with school life, while others continued to do
so up to date. In one of these, (No 177) the pain is said to
have been " dreadful '* and spasmodic, before marriage, and

' Group I being the class without pain. Group III includes those who suf-
fered from the beginning, but slightly.

THE QUESTION OF REST FOR WOMEN.

not to have existed since. In three of the remaining cases, the
patients suffered, not from pain, but from amenorrhea (cases
1 16, 127, 143). The history of each of these is interesting, and
will be analyzed later. In sixteen cases the pain at menstru-
ation was so slight, that practically the patients might have
been ranked in the class of painless cases. Finally seventy
persons suffered from pain decided or severe, in some cases
very severe, or else, instead of pain, were prostrated by ex-
cessive flowing. These latter, however, were in the minority,
only six. Two of these (130 and 146) suffered from severe
dysmenorrhea during the first six or seven years of menstrual
life, but later the pain was replaced by menorrhagia. The
interpretation of such cases is of much importance. These
• general results may be thus tabulated.

TABLE IX. (Groups 2 and 3.)

Severe pain.

Menorrhagia.

Amenorrhea.

Per cent, of preceding.

80 per cent.

Slight pain.

Per cent.

19 per cent.

Among the seventy-three cases of those who suffered
severely from pain, menorrhagia, or amenorrhea, forty-three,
or 58 per cent., exercised while at school two hours and
under a day, frequently not more than one, while twenty-one,
or 28 per cent., exercised three hours and over. Nine cases
are not specified. Among the eighteen who suffered but
slightly, eleven, or 61 per cent., exercised two hours and
under, and seven, or 37^ per cent., exercised three hours and
over.

TABLE X.

—EXERCISE IN SCHOOL LIFE. (Groltps 2 and 3.J

Two hours or under.

Three hours or over.

Severe pain . . .
Slight pain ....

58 per cent.
61 per cent.

28 per cent. (30 per cent of whole).
37 J per cent.

ANALYSIS OF TABLE X. 4^

The proportions do not vary enough to largely explain
the comparative immunity of the second division by a greater
attention to exercise during school life, yet the balance, such
as it is, is in favor of this influence, since in this division 37^
per cent, obtained abundant exercise, while this was the case
with only 32 per cent, of the first division. Individual cases
are not always in accordance with this general average, how-
ever. Thus case 85 was accustomed to only one and a half
hours exercise, yet suffered little pain, while No. 54 exer-
cised five to six hours, yet suffered severe menstrual pain
until the birth of first child.* Nevertheless, from the general
average, we are warranted in concluding that insufficient
exercise during school life may be one factor in the produc-
tion of severely painful menstruation, since among those who
suffered severely, a smaller proportion of girls exercised suf-
ficiently than among those who experienced only slight dis-
comfort.

Upon comparing these results with those obtained from
the first series of ninety cases, in which menstruation oc-
casioned no pain or inconvenience, we find that the pro-
portion of exercise was in them greater than among the
cases of the , second series. This has been shown, page 30.
The proportion of those who exercised over two hours was
S7i P^^ cent., and under, 42I: per cent. If we add together
the numbers of those who suffered very slightly and those
who did not suffer at all, we have a total of one hundred and
eight, of whom sixty-five, or 60 per cent., took sufficient
exercise, while thirty-nine, or 36 per cent., exercised very
little. The difference between the two is 24 per cent, while
the difference between the two divisions of those who suf-
fered severe pain is 30 per cent.

* This patient was treated for subinvolution, but reports herself cured. As
the larger number of very severe dysmenorrheas of early adolescence are asso-
ciated with a narrow os uteri, and this is an index of general lack of development
of the organ, there is an indication of deficient nutritive force in the generative
organs that pight be expected to favor subinvolution.

THE QUESTION OF REST FOR WOMEX.

The family history of j^irls who began to suffer pain with
their first menstruation is most important. Among sixty-
seven persons suffering from severe pain, or else from amen-
orrhea, the family health is said to have been good in twenty-
six, or 38!^ per cent., and poor in forty-one, or 61 per cent.
Among the twenty-six cases, twenty-one are reported simply
as good, one as ver^' good, one as perfectly good, one as per-
fect, one as excellent, one as unsurpassed. The family his-
tory of the forty-one other cases deserves to be tabulated.

TABLE XI. FAMILY HEALTH. (Grolp IL)

(lood.

26, or 385 per cent.

Poor.

41, or 61 J per cent.

Scrofula.

Poor.

Scrofula.

Childhood delicate.

Mother consumptive.

** uterine disease.

" cancer.

Father consumptive.

Childhood delicate.

Parents "

Consumptive.

Father rheumatic.

7«

Cout rheumatism.

Childhood sicklv.

Parents consumptive.

Poor.

100

Consumption.

lOI

(»

III

Sister tuberculous, subi

112

" severely epileptic

TABLES XI-XII.

1^5

Mother menorrhagic.

ii6

" subinvolved uterus

1 20

Sister with uterine disease.

123

Mother •*

126

Sisters "

127

Poor.

129

Gout.

130

Sister endometritis.

131

Family hysterical.

134

Poor.

140

Gout.

144

Mother subinvolution.

146

Uterine disease.

148

Delicate.

149

•I

150

153

159

.Father consumptive.

160

Sister uterine disease.

172

Poor, rheumatism.

Of the eighteen persons suffering slight pain, in ten the
family health was delicate or consumptive, in six only was
good, in two was not specified. As in the table for exercise it
is well to add together, for the comparison of family health,
the group of persons suffering slight menstrual pain during
adolescence, (which wc will henceforth call Group III,) and
of those who did not suffer at all (Group I). The following
table represents the family health of the latter group :

TABLE XII.— FAMILY HEALTH OF GROUP L

Good!
58 cases, or 63^ percent, (i excellent, 2 perfect).

Poor.
33» or 36J per cent.

4 Mother, cancer.
2 Very delicate.

5 Chorea and hemiplegia as child.

THE QUESTION OF REST FOR WOMEN.

22
28
29

30
36

43
46

47
48

49
51

54
50

53
60

85
88

Mother consumptive, childhood delicate.

Not very strong.

Sister epileptic.

Father consumptive.

Mother scrofulous.

Delicate.

Poor.

Mother and brother consumptive.

Sisters invalids.

Mother consumptive.

Very poor.

Not robust. Rheumatism.

Childhood delicate.

*' frail, mother consumptive.

" " " rheumatic.

Mother consumptive.
Delicate childhood.
Eczema in family.
"Bilious."
Uterine disease.
Consumptive. Gout.
Poor.

Very delicate child.
Delicate.
Poor.
Delicate.
Poor.

Father head disease, sister consumptive.
Mother and sister delicate.
Mother rheumatic.

We then have :

TADLE XII.— FAMILY HEALTH. (Groups i and 3.)

58 + 6 = 64, or 59 per cent.
33 + 10 = 43, or 40 per cent.

Health of family good.
Health of family poor.

The difference in the percentages of the two groups — that

TABLE OF GENERAL HEALTH.

in whom family health was good, and that in whom it was
poor — is much lessened when the sixteen cases of "slight
pain** are added to the ninety-one cases of "no pain.'* To'
assist in the interpretation of this fact, it is necessary to
examine the statistics of the general health of the cases in
the three groups thus far analyzed, namely, those who
(Group I.) never have suffered pain at menstruation, those
who from the first have suffered either from severe pain, from
excessive flowing, or from amenorrhea (Group II.), and those
who, also from the establishment of menstruation, have only
experienced slight inconvenience (Group III.). The table is
based on the answers to the seventh question in the circular,
and to the fourteenth, the latter regarding the strength as
estimated by the capacity for daily exercise. Eighty-seven
cases are recorded.

TABLE XIV.— GENERAL HEALTH. Group i.

Good.

Poor.

70, or 80 per cent.

17, or 19 per cent.

The details of this table are given below :

TABLE GENERAL HEALTH. Group Without Pain.

Xo. miles that

No. miles that

Nos.

General Health.

can be walked

Nos.

General Health.

can be walked

daily.

Improving till 24,

fill 15, 1 mile,

Good.

Very strong.

then very good.

now 6-8.

Ciood.

Many miles

Good.

3-5.

Good.

4-6.

Sick headache.

I mile.

Good.

12.

Good.

Indelinite.

Very good.

3-4.

Good.

Long walks.

Always good.

10.

Good.

3 miles an
hour.

Threatened with
phthisis.

I mile.

Good.

3 miles.

Very good.

4 miles.

Good.

4-10.

Nearly perfect.

10 miles.

Excellent.

10.

Nearly perfect.

5-6.

Good.

3-9.

Sound.

3-6.

Perfect.

d-IO-I2.

Excellent.

20.

THE OUESTIOX OF REST FOR WOMEN*.

No. miles that

Nu. miles that

NoN.

(rcncral Health.

can be walketl

Nos.

General Health.

can be u alked

daily
4 till after cd

daily.

( icncrally g'joil.

Very good.

5-S.

child.

(.!onge>live head-
aches at 30.

10.

Gofxl.

9 miles.

IJad. Severe dys-

KxccUcnt.

;-(,.

jvepsia.

Generally goo<l.

il-

r»elicate.

( iikmI.

'>.

Ver\* good.

6-12.

riood.

ri-

CicMul till marriage,

Formerly 6-

Fair.

Indefinite.

now weak.

10.

Invalid from 171025.

^-3.

Kxcellent.

Strong.

now stronger.

Ver\' good.

All day.

($(H)i\.

•>-7.

IVrfecl.

15 miles.

( JcxmI.

Long <li stance

GtM-Ul.

10 miles.

( fOO(].

5 miles.

Not vigorous.

1-2 miles.

Delicate.

^-4.

(^nly fair.

I mile.

^tn»n}» in America.

r}.

Very good, but neu-

Not much.

liad health.

No distance.

ralgic.

Very fine.

3 miles.

( JOO<1.

Not much.

( i<M)(l.

10.

Excellent.

Strcmg.

(iene rally very good

3-5.

Perfectly healthy.

Strong.

Always good.

5-U>-20.

Sick headache.

3 hours.

(iood. Sick head

Strong.

Good.

2 miles.

ache.

Anemia after mar-

I mile.

Not gfKKl. Dyspepsia

1-2 miles.

riage.

( ioixi.

3 miles.

(iood.

5-<>.

( fOod.

S-T).

( Iood.

3-4.

(Iood, but osteitis

2 miles.

Perfectly good.

5-6.

once.

3(>

Fair.

( lOiJct.

5-10.

Hysteria, anemia.

Poor last 5 years.

3 miles.

Anemia.

2-3.

(iood.

.Several.

Delicate.

( lOod.

Robust, not accus-

ICxcellent.

tomed to walk.

( j(K)d.

Several.

Perfectly good.

10.

( fO«)(l.

No distance.

(>3

Ciood.

( iood.

5 miles.

(iood.

( i«)0(l.

5 miles.

Perfect.

10.

Out of eij^hty-six cases on this table, sixteen had deh'-
cate or poor health ; the remaining seventy report them-
selves as in health — good, very good, excellent, or perfect.
The proportions are 19 per cent, and 80 per cent. Upon
comparing the .specific cases on this table with those of Table
X 11. giving the family health of thirty-three cases of this
Group I., we find that seven out of the seventeen ca.ses of
poor health report delicate childhood, hereditary consump-

TABLE OF GENERAL HEALTH. 47

tion, delicate family health, and in one case, uterine disease
in other members of the family. The remaining ten cases,
however, are included among the fifty-eight of Table XII.,
in which family health, and that of childhood, is reported as
good or excellent.

On the other hand, out of seventy reported in good health
and able to walk from three to twelve miles, twenty are re-
corded on Table XII with a bad family history. Thus No.
49, is able to walk nine miles, but the mother was consump-
tive. No 48 reports a frail childhood, but at present writing,
" nearly perfect health " and ability to walk ten or eleven
miles. No. 22, the father was consumptive, but present
health is excellent, and ability to walk reaches five or six
miles, and so on for the other twenty cases. That is to say
that in 28 per cent, of the persons in good health, and free
from menstrual pain, the health had decidedly improved since
childhood and adolescence,* while in fifty cases or 71 per
cent, the family health, and health during childhood had
always been good.

The next Table exhibits the general health of the per-
sons of the second group, those namely who have suffered
severe pain from the beginning of menstruation.

TABLE XV. GENERAL HEALTH. (Group ii.)

Good.

Poor.

24, or 34 per cent.

39, or 56 per cent.

The details are given below :

' It is assumed in this calculation, that the children of consumptive parents,
generally exhibit some effects of inheritance under the age of twenty or not
at all.

THE QUESTION OF REST FOR WOMEN.

TABLE OF GENERAL HEALTH OF SECOND GROUP.

Nos.

General Health.

No. Miles.

Nos.
161

(;cneral Health.

No. Miles.

1 06

(JUO(l.

lUank.

Not strong.

Bet. 25 & 32.

7^)

5. •

51 ! Excellent.

4-5.

*' but neuralgic.

Little.

112 ■ Extremely nervous.

Not strong.

113 Good.

Not stated.

4-5.

114

5-6.

Not strong.

Little.

115 i Anemia.

168

Medium.

15. (?)

1 16 'Neurotic amenorrhea

4-5-

Not stated.

120 'Anemia.

r air.

I -6.

123 |(jOOll.

3-4.

175

Preiiy fair.

125 1 Anemia.

2-3.

Constant improve-

126 Congestion uterus.

1
t'

ment.

127 iCiood, amenorrhea.

4-5.

Very good.

Many.

129 Neurotic.

130

I*iM)r.

7S 'Delicate.

5-6.

132

Good.

46 iFair.

Little.

134

Neuralgic anemia.

99 .Verj' good.

Much.

140

Anemia.

no ! *•

3-4.

143

Good, amenorrhea.

ro.

21 |Good.

145

Very good.

98 , "

1-2.

144

Fair.

III

Poor.

146

Very good.

2-3.

153

Anemic.

.\nemia.

154

I'oor from uterine

Not strong.

disease,

(iood.

10.

156

Severe hysteria.

Blank.

Poor.

Very Little.

Congest, uterus.

«> miles.

Xeur.ilgic.

Good.

Little.

Blank.

•* backache last

lOl

\'ery good.

two years.

5-6.

Kidney disease.

Little.

Good.

Blank,

I*oor. Neuralgic.

1-2.

Little.

Good.

10 miles.

100

3-20.

niank.

3-4.

Hlank.

i(t(i

2 miles.

Excellent.

159

Improving.

Not much.

171

Poor.

Headache.

2 bet. i<)& 25.

172

Not strong.

Out of .seventy oiscs (the three cases of amenorrhea are
not included), seven are blank, twenty-four, or 34 per cent.,
are in good health, thirty-nine, or 56 per cent., in delicate or
decidedly poor health. These proportions are in marked
contrast to those of the first group, where 19 per cent,
reported delicate health, and 80 per cent, good and excellent
health. The amount of exercise taken by the persons of this

ANALYSIS OF TABLE OF HEALTH. 49

second group who consider their health good, is also inferior
to that of the first group. Thus, after subtracting from the
seventy women in good health, of the first group, ten who
report indefinitely in regard to their capacity for exercise,
stating it as many miles, " several miles,** ** long distance,**
etc., we find that the several maximum capacities of the
remaining sixty would, if added together, amount to three
hundred and fifty-five miles. This is an average of about six
miles to each person, while, as the whole table shows, many
profess to be able to walk ten, twelve, or even twenty miles.
In the twenty-four similar cases from the second group, we
must subtract two blanks, two indefinite, as " many miles,**
two as ** very little,** leaving eighteen cases. These give a
sum total of maximum capacity of one hundred and two
miles, or an average of a little over five miles to the indi-
vidual. The difference is about one-sixth excess of exercise
in favor of those who did not suffer pain. But in reality the
difference is greater, since in the first group, all who reported
indefinitely in regard to exercise (lo) speak of being able to
walk a great deal, while of the six exceptions in the second
group, four walked only a little. If we assume that ten
indefinites walked five miles, and the six exceptions two, the
difference between the two groups would remain almost
exactly the same. Seventy women of the first group would
then be shown to walk four hundred and five miles, or an
average of five and five-sevenths, and twenty-four women of
the second group to walk one hundred and fourteen miles,
or four and five-sevenths. The difference is still a mile, but
the proportion is a little higher than one-sixth.

The similar statistics from the eighteen cases with slight
pain are shown in the next table :
4

THE QUESTION OF REST FOR WOMEN.

TABLE XVI.— GENERAL HEALTH OF THIRD GROUP.

Nos.

General Mealth.

No. Miles.

(•encral Health.

No. Miles.

Poor last 2 years.

3-4.

Treat, f r uterine

•

85
56

Ver)' good.
Excellent.

2-3.
Long (list.

disease.
Good.

2-3.
5 m.

105

I )yNpepsia.

Good.

Improved.

<i It

54
102

(^oiul until child-
bearing.

Very little.
Klank.

107

4
06

Stronger.
Very good,
niank.

S-io.
3-

5S
32

Very fair.

Good. Slight neu-
ralgia.

S-9.
Several.

(jood.

6 m.

131 'Ncuriilic.

if>5

Good.

Little.

From this table it appears that twelve, or 26 per cent.,
enjoy good health, while in six, or 33 per cent., the health is
broken, or at least below par. The twelve persons in good
health have a collective maximum capacity for exercise of
sixty-four miles, or an avera<j^e of five and one-fourth. In
this estimate we have counted the report of ** Long distance"
as seven miles, "Several," three, "Blank'* ^as two, and
** Little ** as one. The average is curiously similar to that
obtained from the group of persons who suffered no pain,
and in the same proportion superior to the section of the
second group, where, in .spite of painful menstruation, the
general health was said to be good.

To show the constancy of these proportions we have
made still another calculation from the exercise capacity
tables of the second and third groups, in which the persons
in good health and poor health, i,i\ all the ca.ses on the
table, are taken together. The 13. " Blank " is estimated at
two miles, " Little** at one mile, and "many'* at five. In
the group second then, seventy persons walk collectively two
hundred and twenty-eight miles, an average of three and
one-fourth, while in group third, eighteen persons walk
eighty-two miles, an average of four and five-ninths. Group

TABLE OF EXERCISE.

I., estimated in the same manner, gives four hundred and
thirty-five miles for eighty-seven persons ; or an average of
exactly five miles. These results may be compared better in
a single table bringing them together :

TABLE XVIL— MAXIMUM CAPACITY FOR EXERCISE.

Group I. No Pain.

Average of entire group :
435 miles, or 5 a piece.

Average healthy section :
405 miles, or 5f a piece.

Group 3. Severe Pain.

Average of entire group :
228 miles, or 3J a piece.

Average healthy section :
114 miles, or 4f a piece.

Group 3. Slight Pain.

Average of entire group :
82 miles, or 4J a piece.

Average healthy section :
64 miles, or 5}^ a piece.

Before tabulating the statistics of occupations and of
periodical rest of Groups 2 and 3, it is desirable to analyze
the fourth group — of persons namely who began to suffer
pain or other inconvenience during menstruation only at
some period after its establishment. These cases have been
separated from the rest, in order to distinguish between the
influence of hereditary constitutions or congenital conditions,
and that of modes of life, since the first would be expected
to be felt, if at all, during adolescence ; the second would
only make itself apparent later, and should deepen with the
persistence of its cause.

There are seventy-one cases in this category, or Group 4.*
Of these, forty-three, or 60 per cent., suffered severely, while
twenty-eight, or 39 per cent., only suffered occasionally or
slightly.

These proportions differ considerably from those of the
class in whom menstrual disturbance existed from the first
(sec Table IX.). The result may be contrasted in a single
table :

' The remaining nine cases (see page s6) have not given sufficiently detailed
hbtories.

THE QUESTION OF REST FOR WOMEN.

TABLE XVIII.

Pain, etc., from first menstruation.

Pain, etc., subsequent to 6rsL

Severe.

Slight

Severe.

SliRhL

80 per cent.

19 per cent.

60 per cent.

39 per cent.

The statistics in regard to school attendance of this
group have already been considered in contrasting the whole
of the second class with the whole of the first.

It is desirable, however, to contrast the different schemes
of education in the two divisions of the second class :

TABLE XIX.

Pain

, etc., from the first.
Education.

Pain

, etc., subsequently.
Education.

Common Ed.

Ornamental.

Hii^her.

Common Ed.

Ornamental.

Higher.

28, or 3lt
■per cem.

21, or 23
j>er cent.

40, or 44i>o
per cent.

16, or 22
per cent.

26, or 36
per cent.

30, or 4 C
per cent.

The proportion in the two classes of persons who have
only received a common English education, is 12 per cent, in
favor of the first section. In ornamental education there is
a difference of 13 per cent, in favor of the second section;
and in the higher education, nearly 4 per cent, in favor of
the first aijain. Tlius those who had the least education
were not thereby prevented from being the most precocious
in menstrual suffering ; and on the other hand, those in whom
education was the most prolonged were not predominantly
they in whom pain began a few years after the establishment
of menstruation, /. c, at the epoch when the average course
of study was being extended.

Finally the greatest difference obtains in regard to the

TABLE OF EXERCISE. S3

ornamental sfection which furnishes a much larger proportion
of persons whose menstruation becomes deranged after the
usual period of school life is over.

The next table shows the statistics of exercise taken while
in school. The calculation excludes the third column.

TABLE

XX. EXERCLSE. (Group 4.)

Under Three Hours.

Three Hours and over.

Not suted.

41, or 62 percent.

25, or 29 per cent.

6, or 8J per cent.

This table has been based on the calculation that any de-
gree of exercise less than three hours, is insufficient for a
growing school girl, and the very large proportion of cases
from this group, when only this amount was taken, shows
the influence the poor regime exercises upon the afterlife.
It very closely resembles the per centage table in Groups II
and III, when the pain was experienced from the first,
(Table X), and also Table ij^ of the painless cases. Never-
theless there is 3 per cent, insufficient exercise cases in favor
of the Table of suffering persons, the per centages of really
sufficient exercise being almost identical, while compared
with the Table of those who suffered from the first, excess of
insufficiency is 4 per cent, and excess of sufficiency in the
former table, I per cent. It would follow that insufficient
exercise during school life, exerted somewhat more influence
upon the menstruation after the school epoch was completed
than at the time.

The next table exhibits the family history of Group IV,
compared with the preceding. The health is said to have
been good in twenty-seven cases of the seventy in which it is
recorded, or 39 per cent., and poor in forty-three, or 61 per

' The percentage in table will be found to be the same, if calculated on the
whole number, as in the two groups, the second per centage is 30.

THE OUESTIOX OF REST FOR WOMEN.

cent. These proportions much resemble those of the Group
II, (severe pain.)

TAHLK XXI OF FAMHA' IIKALTH OF FOUR GROUPS.

Group I.

Group 2.

rroup 3.

Group 4.

Good.

5S or 63 «
per cent.

33 or 3f>J
per cent.

(Io<mI.

VtfOT.

26 or 38;
per cent.

41 or 61 1
per cent.

i lood.
Poor.

6 or 37l
])er cent.

10 '^r 62 1
per cent.

Gooil.

27 or 38
per cent.

Poor.

43 or 61
per cent.

Indeed a glance at the above table shows that ihe con-
dition of family health, or health during childhood, was ex-
ceedingly alike in all three of the Groups representing pain,
while in Group I or the painless Group, the proportions of
good health to bad are exactly reversed. There is even a
larger proportion of good hereditary antecedents in this
Group, than there is of poor in the others. Specifications of
poor health are about the same as in the other tables.

The occupations of Group IV are of much importance to
consider.

TABLE XXTI. OCCUPATIONS. (Groit 4.)

Social.

Married.

Teaching.

Miscellaneous.

23, or 31 1'g per cent.

9, or II per cent.

•

17, or 22 per cent.

Art 3

Medicine 7

>ervant I

Missionary I

l-aciory 4

1 lerk 2

I'lioiographs . .. . I

Matron I

I-iterary I

Sister Charitv. . . I

22, or 30 per cent.

It is most important to contrast the Table of Occupations
of Group 4, with that of Group I. For convenience, their
contrast may be shown in a single table.

OCCUPATIONS AND MENSTRUATION.

TABLE XXIII.

Social, /. e. unmarried
and unemployed.

Married.

Teaching.

Miscellaneous.

8 per cent.

I.
IV.

25 per cent.

I.
IV.

29J per cent.

20 per cent.

IV.

31} 5 per cent.

11 per cent.

22 per cent.

IV.

30 per cent.

The term ** Social '* on the table is used to include all un-
married women without special paid employment. On many
of the circulars such persons record themselves as engaged
in housework, on others as having no *.* occupation,** or being
young ladies ** of leisure.** Of the married women of Group
I, twenty-one bore several children, and thus could be said to
have a special employment.

The contrast between the number of married women in
the two groups is most remarkable. While among those who
never suffer pain at menstruation, 25 per cent, are married,
from the group that some time after the establishment of
menstruation began to suffer pain, only 1 1 per cent, are mar-
ried. Again only 8 per cent, of the painless group are recorded
as without special occupations, while nearly 32 per cent, are
so recorded in the second division.

This proportion is higher than that of persons engaged in
Teaching or Miscellaneous occupations. There is a larger
proportion of teachers in the painless than in the painful
group, but the proportion of Miscellaneous occupations is
larger in the latter. It happens, however, that the actual
numbers of the most intellectual and the most mechanical
occupation among these, are almost identical in the two
groups. In the first group are eight cases for medical, and
four for factory work. In the fourth group, seven for medi-
cine, and equally four for the factory.

So far as any inferences can be drawn from these figures,

56 THE QUESTION OF REST FOR WOMEN.

we may conclude that adult women who arc married es-
cape danger of menstrual disturbance in the proportion of
14 per cent., (25-11) and that those who are unmarried
and without occupation, incur this danger in the proportion
of 24 per cent. (32-8.) Finally that among the small num-
bers of occupations examined, teaching would seem to be the
least liable to be followed by disturbance of menstrual health.
This last conclusion, however, cannot be relied upon, since
the proportion of no other occupation given is large enough
to be compared with teaching.

The significance of a table of occupations of Groups 1 1 and

III is rather to demonstrate the extent to which women may
continue work, even though partially crippled by menstrual
suffering, than to show how this could be influenced by
their work, since it existed before any occupation was taken
up. It has been omitted.

It is now necessary to ascertain what proportion of Group

IV retained fair general health and capacity for exercise, even
though acquiring the habit of menstrual pain.

Among the seventy-two persons in Group IV, thirty, or
41 f per cent, had been treated for some form of uterine dis-
ease, while forty-two, or 58J^ per cent, had never been so
treated, thirty-two, or 44 J^ per cent, were in good general
health, while forty, or 55 J per cent, were in poor health. Of
the thirty-two persons in good general health, only five are
said to have had severe pain, in eight cases the degree is not
specified, and in nineteen, it is said to have been slight or
occasional. In the great majority of the cases therefore, when
the habit of menstrual suffering was acquired, it coincided
with a breaking down of the general health.

In regard to the maximum capacity for exercise, calcu-
lated as for the preceding groups, (see Table XVII), it is
found that the seventy-two persons collectively could walk
two hundred and eighty-eight miles, or exactly four a-piece.
This is less than for any group, except that of severe primary

REST AT MENSTRUAL PERIOD. $7

pain. The thirty-two persons in good health walked one
hundred and eighty-two miles, or five and eleven-twelfths
a-piece, while the forty persons in poor health walked one
hundred and six miles, or two and nine-tenths a piece. This
last is very much the smallest on any table, while the aver-
age of the healthy section, as seen, does not differ materially
from that of the groups who suffered no pain, especially of
the healthy section of that group. Unless, therefore, the
habit of menstrual pain resulted from or was associated with
deterioration of general health, it did not affect the strength
or capacity for exercise, nor presumably of work.

The final inquiry refers to the amount of rest observed
during the menstrual period by the persons of Group IV.
Forty-two persons, or 58^ per cent., habitually required rest,
during from one-half day (one case) to one week. In all the
cases but two, this rest was taken. In thirty cases, or 4 if
per cent., no rest was indulged in, except occasionally, and
in only two of these cases was it considered desirable.

Of Groups II. and III. of ninety-one cases, forty-six re-
quired rest ; and all but five of them rested, from a few hours
to several days. This is 5o{ per cent. Forty-four, or 48^
per cent., required no rest. Of course in this number are
included the sixteen cases of very slight pain, and the three
cases of amenorrhea, leaving, however, twenty-five cases of
dysmenorrhea or menorrhagia, when, notwithstanding the
suffering, no rest was claimed.

The statistics of rest for the four groups may be con-
veniently contrasted in the following table :

TABLE XXIV.— OF REST.

Group I.

Groups II. and III.

Group IV.

Rest . . .

No rest .

9, or II per cent.
80, or 88 per cent.

46, or 5o| per cent.
44, or 48 1 per cent.

42, or 58J per cent.
30, or 41} per cent.

58 THE QUESTION OF REST FOR WOMEN.

It is unfortunately difficult from these tables to infer to
what extent the neglect of rest could be blamed for the habit
of menstrual pain gradually developed, since in no instance
does rest seem to have been observed until or unless pain, or
weakness from excessive flow were present ; and the habit
was stopped as soon as, by the cure of uterine disease, or by
improvement of the general health, menstrual discomfort
abated. It is worth noting as a net result, that of two hun-
dred and fifty-two women where the detail is stated, ninety-
seven, or 38 per cent., were in the habit of resting more or
less during menstruation, while one hundred and fifty-five,
or 61 per cent., took no rest at all.

We will now summarize the results obtained from the
analysis of two hundred and sixty-eight cases, whose histories
enter more or less completely into the foregoing series of
tables.

I. Out of this number of women interrogated at hazard,
ninety-four, or 35 per cent., declare themselves to have been
always completely free from discomfort during menstruation.
Moreover, if we add to this number the eighteen from Table
IX, and twenty-eight from Group IV on page 57, who only suf-
fered slightly or occasionally, we have a total of one hundred
and forty, or 59 per cent, of cases where menstruation, so far as
the consciousness of the women went, could not be considered
of sufficient moment to interrupt daily avocations. It is to be
remembered that from these statistics are carefully excluded
those cases where the women, though suffering slight pain,
are more dangerously prostrated by excessive hemorrhage.

If our statistics be combined with those of Brierre de
Boismont given on page 26, we shall have a total of (268 -h
360) six hundred and twenty-eight women. Of these (94-h82)
one hundred and seventy-six were completely free from pain,
(28 per cent.), while (154 + 278) four hundred and thirty-two,
or 6S^ per cent., suffered to a greater or less extent. As
Brierre de Boismont, however, does not distinguish between

GENERAL ANALYSIS. 59

the trifling colic, to which scarcely any attention is paid, and
the severe dysmenorrhea, which temporarily prostrates the
unfortunate victim, his statistics are, for practical purposes,
much less valuable than ours, and the last combination of
them with ours of much less significance than the first.

There remain, however, on our own statistics, one hun-
dred and twenty-eight cases, or 47 per cent., of women to
whom menstruation was a seriously painful, therefore morbid
process. It may be at once asserted that in all such cases
rest, during the existence of such pain, is as desirable as
during the occurrence of any other.

2. Of the one hundred and sixty-two painful cases, /. e.
including all degrees of pain, 53 per cent, had been so from
the beginning ; in 46 per cent, the habit had been acquired.
The importance of this distinction will appear when we dis-
cuss in detail the causes of menstrual pain. It is evident at
the outset, that wherever pain had existed from the age of
thirteen or fourteen, no unremitting occupation, adopted
eight or ten years later, could be held to be the cause of it.
The only occupation to be considered in this connection is
that of study at school.

3. The number of hours spent in study while at school,
the studies pursued, and the number of years occupied by
education, are all a good deal alike throughout our entire
series of cases. Nevertheless, it has been shown {a) that
18 per cent, of the second class (pain) received very little
education, while none are so specified in the first class.
(p) The average for beginning school attendance is younger
in the second class than in the first (see page 37). The most
frequent age in both classes is from five to eight ; but in the
second class (pain) 21 per cent, of these begin under five,
while in the first class it is 13 per cent, (r) The average of
leaving is also nearly the same, and, from the tables, no
reliable conclusions can be drawn in regard to this point.
The proportion of persons who pursued advanced studies

6o THE QUESTION OF REST FOR WOMEN.

beyond the age of twenty-two, was i6 per cent, in the first
class (painless), only 8^ in the second, as observed on page
37. The educational coincidences of menstrual pain are
therefore with more prolonged primary and secondary educa-
tion, but seem to have no connection with higher studies.
(d) Combining the results of Table II., page 31, and Table
XIX., page 52, we find that among those specified from the
painless group (76 out of 94) the proportions of common,
ornamental, and higher systems of education are respectively
26J, i8i, 55^ per cent., while among the persons who suffered
pain it is 27, 29, and 43 per cent. These figures show that
the larger proportion of our statistics have been taken
(accidentally) from among persons comparatively highly edu-
cated. The highest education (at present given to women)
is, according to these proportions, much the most favorable
to menstrual health ; the least favorable is the ornamental
system. This is generally received by a class that figure
apart on the table of occupations, as having no occupation.

4. Throughout our entire series of cases the majority of
persons are shown to have had too little exercise during
childhood and girlhood. Comparatively few have received
anything like a systematic physical education. But the class
who never suffered menstrual pain exercised a great deal
more than the other class. 67 per cent, received a fair share
of exercise, while in the second class, only 47 per cent,
(see page 52).

5. There is a remarkable contrast in the family history of
the persons who never suffered pain, and of those who did ;
and the percentage of good health and bad is almost identical
in those who suffered pain from the beginning, and in those
in whom the painful habit was acquired. By combining the
columns for Groups II. and III. in Table XXI., we have for
persons who never suffered pain, good family history in 63^
per cent., while in those who suffered from the beginning it
was 38, and in those who acquired suffering, also 38 per

ANALYSIS OF TABLES, HEALTH AND OCCUPATION. 6 1

cent. The percentages of poor health are respectively 36J,
61, and 62 J per cent. These figures show conclusively that
a large proportion, two-thirds, of persons suffering at men-
struation, inherit some defect either of general constitution,
or of special tendency to uterine disease, or else have passed
a delicate childhood ; while on the other hand, the very same
proportion, two-thirds, of persons healthy in regard to men-
struation, had passed a vigorous childhood and inherited
strong constitutions.* These facts are all to be considered in
estimating the degree to which pain at menstruation is to be
regarded as a normal character, inherent in a physiological
process.

6. Similar inferences are to be drawn from the tables
showing the actual general health and maximum capacity for
exercise -of persons comprised in the different groups. In
the persons without pain, the average capacity for exercise
was five miles, while many claimed to walk ten or fifteen, a
few even twenty. Among the persons who suffered severe
pain from the beginning of menstruation the average was
three and one-quarter, of slight pain four and five-ninths,
and of acquired pain, four miles. Capacity for exercise was
nearly always in inverse proportion to the habit of pain.

7. From the tables of occupation the principal fact to be
deduced was, that persons without occupation suffered at
menstruation in a much larger proportion than those who
were occupied. On Table XXIII. only two groups are con-
trasted, those who never suffered, and those who acquired
the habit (see page 55). It has been noticed above, that
the persons classed under the head of ** social " or house-
keeping occupations, are largely those who received the
*' ornamental ** education. They are also all unmarried.

* Further that in those whose menstrual health breaks down after several
years, family history seems to be accountable to precisely the same extent as in
those who suffer from the beginning. This circumstance is of great importance
in estimating the influence of occupations that are the apparent cause of the
breakdown.

62 THE QUESTION OF REST FOR WOMEN.

8. Marriage finally (see p*igc 55) is much more opposed
than celibacy to the persistence of menstrual pain in adult
life. From accidental circumstances, the number of celibates
is larger in our series than the number of married women.
Were it not so, we should, as it appears, have reason to find
a much larger proportion of women free from menstrual pain.'

Rest during menstruation cannot be shown, from our
present statistics, to exert any influence in preventing pain,
since, when no pain existed, it was rarely taken (see page
57, Table XXIV.).

In Group IV., where pain had been acquired, the habit
of resting was acquired in many cases with it (58^ per cent.),
but not in all. It is precisely in regard to this group that
the question is pertinent, whether a habit of resting, adopted
early in life, might h.ive prevented the development of suffer-
ing ; but from the table itself, we can obtain no answer to
this question.

Judging by these statistics alone, therefore, we should
say, that immunity from menstrual suffering was to be ex-
pected in proportion to: I. The vigor of health during child-
hood, and the soundness of family histor\', especially in regard
to freedom from constitutional taint of scrofula, consump-
tion, or rheumatism, or family tendency to uterine disease.

2. To the degree of exercise taken during school life.

3. To the thoroughness and extension of the mental
education.

4. To the degree to which general health, and capacity
for exercise, was maintained after cessation of study.

5. To steadiness of occupation.

6. Finally, to marriage at a suitable time.

As regards rest — the most important question for our
purpose — we have seen that the above data do not suffice to

' We do not of course mean to deny that marriage, by means of childbearing,
often become^ the starling point of uterine di>ease, but even this is not alvvays
accompanied by dy>menorrliea.

QUESTIONS. 63

inform us of its influence. We can only assert negatively,
that in a large proportion of cases it has been quite super-
fluous.

Several questions are suggested by this summary.

1. Why does menstrual pain exist from the first men-
struation in some cases, and not until long after in others,
and what is the true cause of it in each class of cases ?

2. Why is it that a large number of persons, though the
minority, suffer menstrual pain, though otherwise in good
health, while conversely, many others (also the minority),
though in delicate or even feeble health, experience no
special discomfort at the menstrual epoch ?

3. Why should pain ever be experienced during the men-
strual flow, any more than during an epistaxis, or any other
natural evacuation? If menstruation be a physiological pro-
cess, for which due provision has been made in the economy,
why should it, in 46 per cent, of cases of persons in civilized
classes of society, create disturbance?

4. Is there anything peculiarly threatening about this
disturbance when it exists, so that such resolute effort to dis-
regard it as is frequently considered desirable for other pain
--headache, neuralgia — should be strenuously discouraged,
as liable to lead to a still greater evil ?

5. Finally, is there anything in the nature of menstrua-
tion that should lead us to expect a necessity for mental and
physical rest, even when no pain was experienced? — the
capital question of the Essay.

It is evident that the answers to all these questions
depend on the Theory of Menstruation, and this is as yet far
from being established upon immovable foundations.

SECTION III.

THEORY OF MENSTRUATION.

AT the beginning of this Essay, a few quotations were
made, showing some of the various opinions that had
been held upon this interesting topic. These opinions may
be divided into three classes, which roughly correspond to
three epochs, of ver^*- unequal duration.

The first is the Theory of Plethora, which considered the
menstrual flux to represent the nutriment, in excess over the
wants of the individual, provided for the wants of the foetus.
With this view was generally associated a cosmic theor>', by
which, in virtue of its peculiar periodicity, the menstrual flux
was associated with the phases of the moon, or other cosmic
phenomena. This theory prevailed more or less, from the
time of Hippocrates to the time of Pouchet.

The second is the famous Ovulation Theory, distinctly
formulated about 1845, which construes the menstrual hemor-
rhage as a subsidiary phenomenon, entirely dependent on
the periodical dehiscence of ovules. Around this theory has
clustered the most brilliant gynecological literature of modem
times. Yet this famous theory is, in these last few years,
being attacked and hard pressed on all sides, and seems likely
to yield place to a third, scarcely yet defined enough to have
a name, according to which ovulation and the menstrual
hemorrhage arc processes coincident but distinct, the latter
being subsidiary, not to changes in the ovary, but in the
uterus preparatory for a pregnancy. For our purpose it is
worth while to examine each of these theories a little closely,
but not in the order stated. The ovulation theory, by right of
preeminence, holds the first place, and must be examined first.

OVULAR THEORY. 65

In the discussion of the ovular theory, it is not necessary
to repeat in detail the history of its establishment, which has
been related so frequently (see Pouchet, Courty, Ritchie,
Raciborski, etc.). For our purpose it is sufficient to dwell
upon the following circumstances that have occasioned the
most discussion. These are, the development of the Graafian
vesicle ; the origin and nature of the ovule ; the periodicity
or continuity of its growth ; the cause of its dehiscence ; the
relation of this in point of time to the menstrual hemorrhage ;
the succession of changes occurring in the uterus in connec-
tion with the flow ; the relations of the hemorrhage to con-
ditions of general nutrition, of the nervous system, or of
vascular tension, etc. ^

Negrier* asserted that at birth the ovaries were homo-
geneous ; that the primary vesicles appeared during the
first year, and first began to attain any size towards the tenth
year. Cruveilhier says : ** They (the ovaries of the foetus)
contain a certain number of very small vesicles, or rather
granulations.** — Anat. Descrip., T. III., p. 649. 1843.

According to Raciborski " all anatomists adopted the
opinion, until lately, that the ovaries of the foetus contained
only the germs of the Graafian vesicles, around which these
latter were formed some years after birth. This author also
credits Sappey with the discovery, that in the ovary of a
child two years old existed 400,000 follicles.* But in 1837,
Carus* already described Graafian vesicles in young children.
In 1864, Henle* counted the follicles in the ovary of the new-
born, and estimated them at 360,000.

The researches of Pfluger on the origin of the follicles
date from 1863. All modern anatomists agree that "the
formation, development, and maturation of the Graafian
vesicles and ova continue uninterruptedly from infancy to

' Recherches sur les Ovaires. * Loc. cit., p. 51.

' Traite d'Anatomie Descriptive. 1S67. * Mullers Archiv, 1S37.

* Handbuch der Systemalisch Anat., Bd. II., p. 484.

66 THE QUESTION OF REST FOR WOMEX.

the end of the fruitful period of woman's life." ' •• The
Graafian vesicles are formed already in the foetus and in the
new born, but they are also found in the adult.* , This last
statement is formally contradicted by Waldeyer. ** The fol-
licles," says this distinguished observer, "appear first at
eighteen or twenty weeks of fcetal life. At this time they
contain the ovule, and a simple lining of epithelial cells,
much smaller than the f^^'g cell."' In 1863, Pfluger* de-
scribed the Graafian follicles as originating in tubular pro-
longations from the peritoneal epithelium, that dip down
into the vascular stroma of the ovary. At a period when
the stroma is not yet solid, it is easy to distinguish these
tubes. Waldeyer compares their invasion to that of the
hair follicles and sebaceous glands in the skin. As they
penetrate, the extremity near the surface becomes gradually
constricted and finally closed, and surrounded by a network
of conjunctive tissue. This, by two and a half years, has
formed a thick capsular layer, surrounding the ovum.' At
this time the ovary has almost the same structure as in the
adult (Waldeyer). ** Follicles more or less ripe, indistinguish-
able by any sign from those of adult women, may be found
in the ovaries of girls from one week to fourteen years old." *
Ritchie, in 1865, relates in detail three autopsies of children
— one at birth, one at sixteen weeks, one at five and one-
half years. In each case the surface of the ovaries was
smooth ; but in the first, two vesicles, in the third, seven or
eight, were found, while the interior of the second was found
to be thickly studded with extremely delicate vesicles, vary-

* Gray, Human Anatomy, p. 753. 2d Etl. i860, p. 710. 1S70.

- Beaunis et Bouchard, Element> d'Analomie I)cj>cnplive, p. 829.
3 Die Eicrstocke, p. 21. 1871.

* Ucbcr die Eierstockc du Saugelhicre.

* Klebs, Die Eierstocke der Sau^^ethiere und Vogel. Arch. Virchow. Bd. 28.
1863.

* Grobe, Ueber der Bau und das Wachslhuni des menschlichen Eicrstocks
Arch. Virch. Bd. 26.

HISTOLOGY OF GRAAFIAN VESICLES. (>7

ing in size from a pin's head to a mere point, and filled with
a milky fluid. In the ovary from the child of five years old,
the largest vesicle was the size of a mustard seed, had an
opaque capsule, and contained a reddish colored coagulum.
The capsule of another was of a brick red color, and con-
tained a coagulum of lighter shade in its central part, but
surrounded by a delicate disc of what appeared to be dark
colored blood.* Two differences, according to Waldeyer,
principally distinguish the ovary of the new born from that
of the adult. The layer of conjunctive tissue surrounding
the follicles (albuginea) consists of one thin layer of fibres, and
little follicles still lie together in grape shaped groups.
His and Grobe describe important changes in the stroma, and
insist upon its increased vascularization, observed at the
approach of puberty ; but from the time that the tubes are
once converted into circular follicles, the structure of these
latter remains essentially the same. Henle (loc. cit.) says
that the wall of the follicle consists of a Tunica fibrosa and
Tunica propria folliculi, the first derived from the ovarian
stroma, the second developed from the lining membrane of
cells — membrana granulosa. Waldeyer admits the existence
of these two layers, but derives both of them from the
stroma of the ovary, in which the original tubular prolonga-
tion of cells had been imbedded. This is also the opinion
of Klebs. Slaviansky describes the same membranes under
the name, ** Perifollicular" layer, as distinguished from the
parenchyma, and admits, with Henle, a membrana propria,
rich in round cells, and an external layer of loose reticulated
conjunctive tissue, composed of fibres and fusiform cells.
The membrana propria, whose existence is denied by Klebs,
is described by Slaviansky as the basement membrane under-
lying the epithelial cells of the membrana granulosa. It is
easily seen in fresh specimens, is originally endothelial, as
can be demonstrated by staining with silver, but finally loses

' Contributions to Ovarian Physiology and Pathology, p. i6. 1865.

68 THE QUESTION OF REST FOR WOMEN.

its nuclei. It does not exist in the primordial follicles (Wal-
deyer). The parenchyma of the follicle i Slaviansky), or con-
tents (AValdeyer), consists of the membrana granulosa, or
the epithelial cells lining the follicle, the liquor folliculi, appa-
rently derived from swollen and dissolved cell protoplasma,
finally, the ovule surrounded by its discus proligerus. The
small follicles measured 50-60 u., the larger I -1. 5 mm, the
ovules 35-10 u. Ritchie says, the follicles vary in size from
the bulk of a coriander seed to that of a small raisin. The
principal difference of opinion between Pfluger and Waldeyer
refers to the precise origin of the ovum cell. Pfluger de-
scribes certain large cells with clear nuclei, distinguishable in
the mass of germinal epithelium of the abdomen, which may
be seen in the embryo to enter the open mouths of the flask-
shaped prolongations. These he considers to be the original
ova, and hence distinct from the epithelium of the follicle.
But according to Waldeyer, the ovum is derived from one of
these epithelial cells, which simply increases in size. The
ovule and epithelium are both therefore directly derived from
the germinal epithelium on the surface of the ovary. Thus
remotely, from the mass of cells constituting the Wolffian
body. His' demonstrates that the reproductive cell must
be an epithelium, since its capacity for growth is required to
transcend that of all other elements, and this capacity per-
sists longer in epithelial tissues than any other.' Schrocn's
opinion that the membrana granulosa is derived from con-
nective tissue is in disaccord with the philosophical necessity
is justly insisted upon by His.'

* Un>cro K'^rpcr Forme, p. 152. 1S75.

' Rapidity la in imerse proportion to duration ; the nen'ous system is most
rapidly <leveloped, and earliest arrested in its growth, so that it cannot be regen-
erated after birth. The eiMihelium is the slowest, and growth persists after birth.
The mu-icul.ir ti>>ue is interme»liale between the two. See also remarks of Paget,
that "epitlielial siiucture> aie liable lo s]^ontaneous death and extrusion, as hair,
teeth, epi iermi>." — Surj^ical Pailmlogy, p. S. The ovule, as an epithelial structure,
would -imply follow this general law.

• Spencer ^Prin. Biol., p. 221) ol)ser\'cs that these modified epithelium cells

DEVELOPMENT OF FOLLICLES BEFORE PUBERTY. 69

So far therefore as regards the complete Graafian vesicles,
containing completed ova, it is certain that they exist long
before puberty, or the establishment of menstruation, and that
not in a rudimentary condition, but large and completely
formed.

Nor is this all. The gradual increase in size of the ovum,
known as the process of its " ripening or maturation," fol-
lowed by a peculiar retrogression or atrophy, is also observed in
childhood. The function of the ovary (maturation of folli-
cles), is exercised not only in adult women, but before men-
struation, and during childhood.' But when during childhood
the follicles have attained the size of a pea ot ovqt they do not
rupture^ but are submitted to a physiological involution. This
differs from that following rupture, when a corpus luteum is
formed, in that it is effected by a sclerosis, instead of fatty
degeneration. The cavity becomes filled with a granular
mass composed of fusiform, round and oval cells, upon which
the wall retracts irregularly until finally no trace of the follicle
remains but a grayish spot representing the cicatrice."
Waldeyer declares, that the abortion of ovules continues not
only throughout childhood, when they never rupture, but
also in adult life. ** Ovaries contain many multiple, folded
homogeneous, brilliant membranes surrounding a granular
and fibrous mass, which can hardly be interpreted otherwise

are not remarkable for their complexity, but rather for their simplicity. They
are cells which have departed but little from the original and most general type.
Not peculiarly specialized, rather unspccialized. It is well known that Kblliker
derived spermatozoa from epithelium.

* Slaviansky, Loc. ci^

* The entire evolution of the vesicle would therefore be effected by prolifera-
tion of its cellular contents. But after puberty, the perifollicular layer is more
vascularized, and an increase of tension in its blood vessels, causes an effusion of
fluid into the cavity. The pressure exerted upon this fluid by the stroma, is
transmitted to the point on the wall where there is the least resistance, causing
their gradual thinning and final rupture. A phenomenon of simple cell nutrition
has been replaced by one dependent on hypersemia and changes in blood
tension.

70 THE QUESTION OF REST FOR \YOMEX.

than as the remains of aborted follicles.* In 1864, Henle de-
scribed these same cicatrices consisting of ** a brilliant struct-
ureless multiple folded membrane, forming a vesicle filled with
conjunctive tissue, and \\'\\\c\\:iTQ probably to be considered as
simply collapsed follicles." * Ritchie maintains that the Graaf-
ian vesicles even rupture during childhood, but then by circu-
lar shaped capillary sized pores, through which the transparent
granular fluid may be discharged. The cicatrices left by the
rupture of vesicles that coincides with menstruation, and
after the formation of a corpora lutea vil menstrulia, are
linear and irregular.

" Cicatrices are found on the surface of children's ovaries,
indicating the ripening of follicles, but there is no observation
upon human beings showing that previous to puberty, an
ovum has escaped from a Graafian follicle. Puberty and sex-
ual maturity do not depend upon the state of development
of the Graafian follicle and ovule, because these exist from the
second or third year. The ovule, germinal vesicle and germ-
inal spot, have almost the same dimensions as in adults ; but
in the latter, the number of ripe Graafian vesicles is somewhat
larger than in the child. During childhood the ripe follicles
undergo a retrograde metamorphosis without bursting. The
Liquor folliculi is gradually absorbed, the membrana granu-
losa falls into fatty degeneration, the cavity becomes smaller,
the ovule granular, and finally dissolves."

Ritchie has abundantly demonstrated the presence of
large Graafian vesicles, filled with transparent fluid, project-
ing above the level of the ovary, apparently just ready to
burst, in the bodies of women who had died 'in childbed, or
after the persistence of prolonged pathological amenorrhea.

* Loc. cit. p. 27.

* Whether, observes Henle, the follicle which contains a ripe ovum must neces-
sarily burst : whether the bursting only takes place at the time of menstruation,
or at other times, in consequence of coitus, . . . are questions to which no
answer at present can be given. Ilandbuch. Bd. II. p. 488.

POUCHET'S LAWS. 7 1

The positive evidence for the existence, progressive de-
velopment, and regressive atrophy of the Graafian vesicles
and ova both previous to the attainment of reproductive
powers, and at various periods in relation to menstruation,
and the consequent independence of this process upon that
of menstruation, is negatively much strengthened by a care-
ful examination of the evidence upon which the theory of
dependence has been based.

The original advocates of this theory, more especially
Bischoff,* Raciborski," and Pouchet,* were first of all occu-
pied in proving that the bursting of the Graafian vesicle,
and dehiscence of the ovule, occurred spontaneously, and
independent of coitus. The exclusive association of this de-
hiscence with menstruation, was originally a pure deduction,
une vue cT esprit y adopted as a corollary from the experiments
which discovered ruptured vesicles in the lower animals, sacri-
ficed during the rut, during which period they had been sedu-
lously isolated. Pouchet announces the following ten Laws,
as resuming the Theory which, according to Virchow, has
revolutionized all our ideas in regard to this great depart-
ment of Anthropology.*

1. The human species and mammiferae are subjected to
the same fundamental laws.

2. Throughout the animal kingdom, generation is effected
by means of ova which exist previous to fecundation.

3. Many obstacles oppose the possibility of contact be-
tween the seminal fluid and ovules still contained in the
Graafian follicles.

4. Fecundation can only take place when the ovum has
acquired a certain degree of development after its separation
from the ovary.

' Beweis ueber der Begattung. 1854. ' Traitc de la menstruation.

* Theorie del'Ovulation spontan^e. It is accepted unequivocally by Courty,
Longet, Liegois, Brucke, Virchow, Beaunis, etc. It has always been disputed by
Aran.

* Gesammdt. Abhandlungen, p. 736.

^2 THE QUESTION OF REST FOR WOMEX.

5. Throughout the animal series, it is incontcstible that
the ovary discharges its ovules independently of fecundation.

6. In all animals ovules are emitted at fixed epochs, in
relation with the periodical surexcitation of the genital
organs.

7. In the human species, and the mammiferae, fecunda-
tion never occurs, except when the emission of ovules coin-
cides with the presence of the seminal fluid.

8. The menstruation of the woman corresponds to the
phenomena of excitement, which is manifested at the rutting
seasons in various animals, and especially in the females of
the mammiferae.

9. Fecundation is in constant relation with menstruation ;
therefore in the human species it is easy to rigorously
establish the intermenstrual epoch at which conception is

physically impossible.

10. In the human species and mammiferae, the ovule and

the sperm normally encounter each other in the uterus and
the neighboring region of the Fallopian tubes, and it is here
that fecundation takes place.

Against the first five of these laws the most scrutinizing
modern researches have failed to raise the least objection.
It is quite othenvise with the sixth, and it is important to
examine carefully the- proofs upon which so weighty a law is
made to repose. Those are divided by Pouchet into two
classes, direct and indirect. The direct proofs are as follows :
In the entire biological series, when the organism of the animal
has reached its maximum of development, certain phenomena
are exhibited by the sexual organs, indicating a profound ex-
citement, and soon afterwards, the ovary increases in size, the
ovules, which had been in a latent state and of extremely min-
ute dimensions, grow rapidly, and when they are sufficiently
organized to be efficaciously impregnated, they are expelled
from the germiferous organ, and carried towards the exterior.
In many Invertebrates, especially insects, the organism is ex-

POUCHET'S SIXTH LAW. 73

haiusted by a single crisis of ovulation. In the lower Verte-
brates, as fish and reptiles, the turgescence of the ovary only
occurs once a year, at the same epoch that the testicles of the
male increase in size. Where ovulation and fecundation are
normal, they are effected at a time of the year most favorable
for the development of the unprotected eggs. In oviparous
animals, domesticity, which increases chances of protection,
markedly diminishes the interval between the rutting seasons.
Nevertheless, after every period of excitement an egg is laid,
and in mammiferae as shown by the experiments of Cruik-
shank,' Haighton," Bischoff,' De Baer,* when the Fallopian
tubes have been tied at the beginning of the rut, the Graafian
vesicles are found ruptured, the ovum escaped, and often to
be detected in the oviduct.

Pouchet himself only describes observations of corpora
lutea found in animals dead during pregnancy or after partu-
rition, and alleges them as proof that the follicles rupture with-
out the influence of coitus or the contact of the seminal fluid.
He also describes the ovaries of two young girls, virgins,
which offered Graafian vesicles in various stages of develop-
ment, and also corpora lutea, showing that these latter had
formed without fecundation. But those observations, while
proving the spontaneous development and dehiscence of the
ovules, do not afford the least proof that the latter only oc-
curs at the epoch of the rut. As already observed, the crucial
experiments of Raciborski and Bischoff, who, dissecting vir-
gin mammiferae after the epoch of the rut, discovered ova in
the Fallopian tubes, proves that the Graafian vesicles burst
at this time, but does not disprove that they burst at any
other.

Bischoff was fortunate enough to examine the ovaries of
four women, who died during menstruation.* In three of the

> Phil. Trans. 1797. « Phil. Trans. 1797.

' Loc. cit. * Epistola de ovi mammalium. 1872.

• Bcweis der period. Reifung und Loslosung der Eier. 1844.

74 THE QUKSTION OF REST FOR WOMEN.

cases were found a Graafian vesicle ruptured and filled with a
clot of blood; but, /// the fourth^ only an unruptured vesicle.
Pouchct himself has never had the opportunity to make a
similar observation,^ and he contents himself with purely
deductive reasoning." *' Since in the mammiferae, the epoch
of the rut is also that of the excitement of the Graafian follicles,
and of the expulsion of ovules ; as this period is equally
marked in many mammiferre (sow, ape) by an oozing of
blood more or less apparent upon the surface of the internal
genital apparatus ; finally as it has been shown, that female
mammiferaj which have been castrated no longer manifest
the phenomena of the rut, and that, according to Robert,
menstruation ceases in the women of central Asia who have
been submitted to this cruel operation : it must be conceded
that phenomena which have the same seat, the same causes,
the same effects, are phenomena not only analogous, but per-
fectly identical." (p. 227.) Again, (p. 244) in the chapter
dedicated to showing the identity between menstruation and
the rut, (7th Law) Ponchet says : ** In women, as has been
proved by observation on the mammifenr, it should be during

this period that the Graafian vesicles develop and experience
the internal hemorrhage destined to expel the ovule formed
in their cavity, but they do not yet open, f he difficulty of
observations in regard to this subject in the human species,
only permits us to support our view by analogy : but in this
case, the analogy is so evident that it is impossible to resist
it. . . . It is entirely at the end of the catamenial flow,
that the follicles open and their ova are expelled.

'* The diffieulties afforded by autopsies prevent us from prov^
ing this in the human speeies, but the observation of the great
mammifenc render the assertion not doubtful." We believe,
on the contrary, that the great variety in the phenomena of

* Loc. cit. p. 240.

' It is iliis cliain of reasoniii;^ which constitutes his so-called " Indirect Proof"
of the Positive theory of Ovulation.

MENSTRUATION AND THE RUT. 75

the rut offered by different species and classes of animals,
and especially the variability in its repetition according to
variations in the habitus, media, etc., of the same animals,
should strictly forbid us from drawing inferences from any of
the lower animals to be unqualifiedly applied to the human
race.

In regard to this mode of reasoning, we think Ritchie's
remarks are perfectly applicable : ** The reasoning of many,
at present, on the connection of menstruation with the
emission of the contents of the ovarian follicles, resembles
that formerly employed on the relation of impregnation to
what are termed corpora lutea, for as there, the corpora lutea
discovered in the ovaries of animals after fecundation were
regarded as the necessary results and indubitable proofs of
that event, to the exclusion of the rut which went before, so
now, because this latter condition in animals is always, and
the process of menstruation in women is usually, succeeded
by the rupture of some of the vesicles of the ovaries, these
states (rut and menstruation) are often considered as the
indubitable consequences of the periodical extrusion of ova,
to the shutting out of view of the independent vital powers
of the ovaries, existing antecedently to both, and of which
they are merely correlative effects.*'

The arguments ofWagner (Hand worterbuch, art. Zeugung,
p. 878) in support of the unqualified dependence of menstrua-
tion upon the bursting of a Graafian follicle are also mainly
analogical. But he adduces the following positive evidence.
If menstruation in the woman really signify the periodic
return of that condition which we call rut in animals, it is
above all necessary that it be shown to be accompanied by
the ripening and dehiscence of an ovule ; and indeed, after
recent experiments, this cannot be doubted. ... So often
as the corpse of a woman, whether married or virgin, has
been examined during menstruation or shortly after, has a
completely ripe or else a burst follicle been found. The

76 THE QUESTION OF REST FOR WOMEN.

author refers to Ecker, Tanzer, Ritchie, Argcnti, Gerres,
HyrtI, Leocatclli, Lcthcby, Coste, Meckel, Hannover, Ger-
lach, Dalton. He then relates three cases himself, where he
found a corpus luteum at the time of menstruation.

But we know that the ov^aries are sometimes filled with
mature vesicles, and ova are bein*j constantly extruded, in
every form of amenorrhea, and during the normal absence of
menstruation ; and also that this latter function is often
accomplished without the rupture of an ovarian follicle.
Ritchie quotes the autopsy of a virgin of sixteen who had
never menstruated, and who died on the sixth day of typhus
fever. Ovaria were covered with several mahogany-colored
points, in one of which was a capillary-sized foramen which
led into a Graafian vesicle about as large as a small grape,
in which was a little blood.

De Sinety relates the autopsy of a woman who died of
phthisis after five months amenorrhea, and a recently rup-
tured Graafian vesicle was found at the autopsy. (Quoted
in American Journal of Science, July, 1874.)

In an autopsy recently made by the present writer, of a
woman with advanced chronic nephritis, who died thirty
hours after confinement at term, vesicles perfectly correspond-
ing to Ritchie's descriptions were found, two in one ovary,
one in the other.

Williams (Proc. Royal Soc, No. 162. 1875. Journal
Obstet., Feb., 1876, p. 7271) quotes twenty-eight cases exam-
ined by Reichert, in which the genital organs showed signs
of menstruation. In one case the follicle had ruptured. In
four the follicle had matured before hemorrhage began, in
one of which the follicle had actually ruptured, and hemor-
rhage had taken place into the decidua menstrualis. Reichert
concludes that the rupture of the Graafian follicle takes place
at an early stage of the menstrual flow. Williams examined
sixteen cases. In twelve of them rupture of a follicle or
hemorrhage into its cavity had occurred before the return of

DEHISCENCE OF OVULES. ^7

the catamcnia : In one it was doubtful whether rupture of the
follicle or the appearance of the discharge would have taken
place first ; in two a menstrual period had passed without
maturation of a follicle ; and in one a periodical discharge
was imtnincnt^ though the ovaries contained no matured Graa-
fian follicle. It is not improbable that the follicles found in
the three last cases, and which were enlarged to the size of a
pea, would have become matured by the next return of the
flow. Williams concludes that the rupture occurs, as a rule,
before the appearance of the monthly flow with which it is
connected. We think the just inference may be drawn, that
the relations of the rupture of the Graafian vesicle to the
uterine hemorrhage are very variable ; or, as Tilt says (Loc.
cit. p. 28), menstruation and ovulation are shown to be paral-
lel facts, but their causal dependence is by no means proved.
In opposition to the statements which assume to repose
upon such an accumulation of facts, Beigel ' observes that
" the opinion which makes menstruation the consequence
and expression of ovulation is supported, apart from theoret-
ical grounds, upon a very few eases y in which ruptured folli-
cles have been found in the ovaries of women who have died
during menstruation. The number of these cases is extremely
smally and the consequences which have been deduced from
them are paralyzed by those autopsies where death, having
also occurred during menstruation, such follicles have not
been found. Ashwell has had occasion to examine three
cadavers whose ovaries, although death took place during
menstruation, off*ered no traces of a rupture of a Graafian
follicle. In one of these the woman had menstruated regu-
larly for many years ; yet the ovaries were perfectly smooth.
Beigel also quotes the famous autopsy of Maria Manning,
performed by Paget, as affording a weighty demonstration
against the ovulation theory. Twelve hours before death
the woman began to menstruate. At the examination the

* Die Krankheiten des weiblichen Geschlechts. Bd. I. p. 307. 1874.

78 THE QUESTION OF REST FOR WOMEN.

ovaries wore found of a medium size, and covered by numerous
cicatrices. In the right ovary, three Graafian follicles pro-
jected somewhat above the surface, appeared healthy, and
were filled with a clear serous fluid. A fourth follicle was
very large. The left ovary contained a completely developed
and prominent Graafian follicle. Ovules were sought for in
vain. The surface of the ovaries was somewhat more vascu-
lar than usual, and there was one place especially vascular-
ized, but not the least trace of the recent rupture of a vesicle
or dehiscence of an ovum. In the right ovary was a little
cyst, or several months old corpus luteum.'

That the dehiscence of the ovule is not, in the human
species, exclusively associated with menstruation, may indeed
be positively proved by all the cases, now tolerably numerous,
cf conception at intermenstrual periods. Pouchet is so con-
vinced of the necessity of this corollary from his sixth law
that has been formulated in his ninth, that he insists with
vehemence on the impossibility of fecundation except at
periods approaching that of menstruation. Raciborski, how-
ever, is compelled to admit that this so called law is not
invariable. The writer of this Essay is acquainted with at
least eight cases, where conception was effected fourteen days
after a menstrual period. In three other cases, avoidance of
marital intercourse during the first twelve days after men-
struation preserved sterility, while conception took place as
soon as this period was invaded. But even a few opposite
examples, and they could certainly be abundantly multiplied
by the experience of every physician, are sufficient to throw
discredit on the doctrine which places dehiscence of ripened
ova exclusively in the fortnight immediately following a
menstrual period.

Dr. Oldham says : ** Cases are known to me where con-
ception has occurred ton, twelve, twenty-one days after the

* \Vc >liall refer again to this aulop^^y in speaking of the vascular phenomena
of nion:>trualion.

CONCEPTION AT MENSTRUAL PERIODS. ' 79

cessation of menstruation, and although I am prepared to
admit a greater disposition for conception immediately after
the monthly flux, I nevertheless possess no facts that should
contradict the opinion that the human female may be im-
pregnated at any time after the menses.** *

Beigel quotes Hirsch* as giving a case where conception
occurred twenty-two days after cessation of the menses.
The author lays stress on the well-known fact, that among
the Jews intercourse is forbidden during five days before and
seven days after the menstrual flow, yet the fertility of this
people is remarkable.

These facts are of all the more importance, on account of
the mass of evidence which has been accumulated to show that,
until the Graafian vesicle has ruptured, the ovum cannot be
fecundated. In some cases where coitus at intermenstrual
periods has proved fruitful, it has been assumed that the
spermatozoa have remained in this canal until the menstrual
period following their entrance, when an ovum is liberated to
meet them. This is the interpretation offered by Dr. Ward,
of a case where conception was effected, nine days before the
period of menstruation, which, however, did not take place.'
But this explanation is a pure assumption based on the un-
qualified acceptance of the theory, that the dehiscence of
ova never occurs except at a menstrual period.

From what precedes, two facts of importance for our pur-
pose may be considered acquired : First. The formation of
ova is a nutritive phenomenon that exists throughout child-
hood, and therefore before the acquisition of reproductive
powers, or the exercise of sexual functions. In its origin and
appearance a simple epithelial cell,* the ovum developes and

* Quoted by Tilt, Ovarian Inflammation, p. 67. 1862.

* Said to be in Schmidt's Jahrbucher, 1854, but I have been unable to verify
the quotation.

' New York Medical Journal. 1875.

* Although even before fecundation it has ceased to be a cell, and has devcl-

8o THE QUESTION OF REST FOR WOMEN.

atrophies according to the laws governing epithelial tissues.
Second : The characteristic change in the history of the
Graafian vesicles that is observed at puberty is their rupture
when arrived at a certain size, which rupture is followed by
an escape of the ovule and its descent into the uterus.* In
animals the phenomena of the rut are constantly accompanied
by the rupture of one or more follicles, and in a certain
number of autopsies of human females, similar conditions have
been found to coincide with menstruation. But it is peremp-
torily demonstrated, both by autopsies, and by the fact of
intermenstrual conceptions, (a) that the rupture of folHculus
may occur not only independently of coitus but in the absence
of menstruation ; (d) that menstruation and coitus may occur
without the rupture of follicles. The description of the au-
topsy given on page 78, shows that the hyperaemiam question-
ably present in uterine tissues, (or part of them) at the time of
menstruation, extends to the ovarian stroma, and even to the
perifollicular layer of the Graafian follicle. Now it is indubit-
able that uterine hemorrhage, indistinguishable in appearance
or clinical phenomena from that of menstruation frequently
occurs under the influence of any cause that either accelerates
the circulation, or raises arterial tension, or both. Hence the
" uterine epistaxis,*' in the first stage of fevers,' or the '* bringing
on of the courses,** under the influence of agitating emotions
The advocates of the ovular theory of menstruation, should
suppose in these cases, that the ripening of a Graafian follicle
had been hastened by the acceleration of the circulation,* and
that ** the irritation ** thus produced had occasioned the men-
oped lo a complex organism by fusion with elemenls from the discus proligenis.
(Waldcyer.)

* Ar> wc have seen, some autliors admit a peculiar kind of rupture even during
childhood, but we do not think this to be sufficiently proved.

* Pointed out by Clublcr.

^We saw the other day a lymphatic gland in the neck of an infant, that had
been long indolently engorged after na-ial irritation, sudiienly begin to suppurate
at the moment that, with increasing health, the circulation became more active.

PFLUGER'S THEORY. 8 1

strual hyperaemia. But it is purely gratuitous to assume this
necessity, and certainly inconsistent with theory of a fatally
periodical cycle in the ripening of the ovarian bud. In the
few cases, (we do not at this moment recall any,) where fol-
licules have been ruptured coincidcntly with such irregular
*' menstruations,*' the rupture must be considered the conse-
quence of the rise of vascular tension, not its cause. In these
cases at least, that cause is admitted to be general.

We say these facts are of considerable importance for our
purpose, because since the promulgation and almost universal
acceptance of the ovulation theory, the peculiar changes sup-
posed to take place in the Graafian vesicles at each menstrual
period have been supposed to involve a peculiar expenditure
of nerve force, which was so much dead loss to the individual
life of the woman. The idea that menstruation was the ex-

pression of sexual excitement, existed before the ovulation
theory (Lecat. Emett, see ut supra,) and is still maintained
by such writers as Beigel who nevertheless reject this latter
theory altogether. Nevertheless, it is principally under its
influence that the growth of the Graafian vesicle and of its
contained ovum, has come to be regarded on an entirely dif-
ferent plane from the nutritive phenomena of other cells, and
as causing a special irritation of the nerves of the ovary, re-
flected to the entire nervous system. According to Pflugcr the
gradual accumulation of this irritation, finally determines by
reflex transmission the afflux of blood to the uterus and
ovaries which constitutes the catamenial flow.* According to
Rouget, whose theory we must presently examine in detail,
this irritation is sufficiently intense to determine a true erec-
tion of all the internal organs of generation. Now whatever
view may be held of the periodical hyperaemia of these
organs, we believe that sifting of the evidence leaves no
plausible pretext to separate the growth of the generative

* This theory is adopted by Barnes and many other gynecologists,

82 THE QUESTION OF REST FOR WOMEN.

epithelium from the general phenomena of nutrition, nor to
ascribe to it any special nervous or sexual influence.

Indeed the assumption (for it is scarcely more, though so
imposingly supported by authority) of a periodical nervous
crisis excited by a periodical development of reproductive
cells, serves to confound the two aspects of the reproductive
apparatus in women which ought to be kept entirely distinct,
namely, the reproductive and the sexual. Reproduction is
essentially a process of nutrition.* From the lowest infuso-
ria* to man, the fusion of two cells, either derived from one
individual (agamogenesis) or two (gamogenesis), each cell
concentrating in itself molecules representative of the organ-
ism from which it is derived,' constitutes the essence of this
mighty physiological process. As sex is secondar>' to the
necessity for complex development, of which it is a conse-
quence/ so sexual instinct and excitement are entirely subor-
dinate to this fundamental fact of the increase in the powers
of development of one cell by the absorption of the material,
and by the influence of the molecular forces of another.*
This sexual fusion is again a simple extension of an earlier
intraovular fusion, apparently necessary to complete the
maturity of the female cell, or fusion between the vesicle of
Balbiani and the germinal vesicle (Balbiani, l^ernard, Loc. cit.).

The perfectly mature ovule indeed cannot be considered
as a simple cell. The follicular epithelium combines with
it, having first formed the discus proligerus. Already, there-
fore, a complex organism has developed from the originally

* Sec Claude liernanl's l^eclures at the College of France, published in the
Revue des Coins SciciUirKjucs. 1S74.

' See Balbiani, Sexual Generation in In^u^oria ; Journal Browii-Sequard,
T. I. 1858.

^ Danvin, Theory of Pangenesis ; Variations of Animals under Domesticity.
Gallon, Journal of Authropolog. Institute, 1876.

* Spencer, I'rinciples of IJiology ; Hirtli, Marriage of Near Kin.

* See Ilacckel, Anthropogenie ; His, Loc. cil.

REPRODUCTION IN WOMAN. 83

simple epithelial cell, before it becomes surrounded by
spermatoza.

The sexual instinct or impulse is necessarily absent in
certain large classes of animals ; namely, in all who propagate
asexually, or by the fusion of cells, both of which are derived
from the same individual ; and must exist in a modified form
in all oviparous animals, as fishes, in which ova are fecundated
after complete separation from the body of the female. Now
it is precisely in these animals that the periodical growth of
ovaries assumes the most marked proportions ; in other words,
the phenomena of reproduction are effected principally by the
one element of increased nutrition. The extrusion from the
body of the products of such increased nutrition is accom-
plished without sexual congress, and in a manner analogous
to the processes of defecation and micturition. In animals
in whom the union of the sexes is essential to fecundation,
whether the eggs be impregnated while still in the body of
the female, or at the moment of emission, as in frogs, a
curious difference exists between the two sexes in regard to
the expulsion of the reproductive cell. In the female, this
occurs spontaneously; in the male, normally, only as the
result of sexual intercourse. The theory of spontaneous
ovulation means precisely that in the female the essential
part of reproduction can be effected without any sexual act.
The superior contribution to the nutritive element of repro-
duction made by the female is balanced by an inferior de-
pendence upon the animal or sexual element ; in other words,
she is sexually inferior. This is still true even when the
manifestation of sexual instinct coincides with the dehiscence
of ova, since the gratification of the instinct is not necessary
in order that the eggs may be laid. It is especially true of
the human female, in whom, in the immense majority of
cases, ova dehisce when the sexual instinct is not only
ungratified but unawakened. This statement would hold
even were it proved that the dehiscence of ova took place

84 THE QUESTION OF REST FOR WOMEN.

exclusively at menstruation, but since, from what precedes,
this famous doctrine is, after all, unproved, the separation of
the sexual and nutritive elements of reproduction in the
woman must be considered to be complete.

But the Graafian follicles, however important, do not
comprise the entire tissue of the ovary, nor, even in the
ovular theory, does the dehiscence of ova constitute all the
phenomena characteristic of the establishment of puberty or
of menstruation. As regards the ovaries, the most impor-
tant changes observed as the period for menstruation ap-
proaches, are to be found in the stroma and blood vessels.
We have already mentioned Waldeyer's remark that the
albuginea becomes much denser at this age. He attributes
its increase to the nutritive irritation exercised on the stroma
by the constantly developing follicles imbedded in it. As
the ovary grows older, the stroma is further modified by the
great increase of blood vessels, and also by the presence of
smooth muscular fibres. The arteries of the ovary are early
developed, and become helicine like those of the uterus.
Extremely numerous branches reach the periphery of the
organ and the Graafian follicles, and these are much more
highly vascularized at puberty than during childhood (Grobe,
Waldcycr, Ritchie). At the base of the ovary exists a
plexus of bloodvessels so rich as to constitute a tissue anal-
ogous to the corpora cavernosa, and which, since Rouget,
has been called the bulb of the ovary. It is this physiolo-
gist, in a memoir become famous,* who has described with
the most care the vascular tissue of the internal organs of
generation, demonstrating, by means of injections, a richness
of bloodvessels hitherto unsuspected.

Rouget first describes minutely the disposition of blood-
vessels in erectile tissues, disputing ^Iiller*s assertion that in
these the arteries terminate in culs de sac, and describes them

* Journal (le Phy>iol., Browii-Scquard, 1S59. Rouget's thesis was passed
in 1S55.

KOUGETS THEORY. 85

as forming bouquets whose branches twist themselves into
brusque spirals, interlaced and anastomosed into vascular
knots. These persist during erection, instead of being effaced
as would be simple flexuosities. The veins and capillaries also
form enormous dilatations and anastomoses, and the whole
vascular mass is contained in meshes of smooth muscular
trabeculae. Such erectile tissue exists at the hilus of the
ovary, in the parenchyma of the ovary, and above all in the
body of the uterus, but exclusively in the human female. No
other mammifer presents a development of vessels sufficiently
considerable relative to the parenchyma to constitute erectile
tissue. When the utero-ovarian vessels were injected, the
entire pelvis being placed in a vessel of warm water, the
body of the uterus rose in the pelvis and remained, ascended
and curved forward, so long as the erectile tissues were dis-
tended. The same phenomenon was observed in the ovary,
but less marked ; no change took place in the Fallopian tube.

Rougct's descriptions and diagrams have been copied into
most systematic treatises on diseases of women. »

His description of the muscular fibre of the ovary is as
remarkable as that of the bloodvessels. Before examining
that of the human female, he describes muscular planes in
various animals, which so envelop the ovary as to guide the
eggs to the oviducts. In cartilaginous fishes, the eggs fall
into the peritoneum, where many are lost. Those which sur-
vive are pushed towards the oviduct by contractions of the
abdominal walls. In scaly reptiles, the muscular layer
(mesoarium) envelops the oviduct and ovary, and in contract-
ing draws them together. In birds (the hen), the mesoarium
is very well developed, and can be seen with the naked eye.
In birds the peritoneal fold (broad ligament) essentially con-
sists of muscular fibres. " In women this muscular tissue
does not form a continuous membrane, but a species of

* See Courty, also Thomas, Diseases of Women : Grailley Hewitt. Liegois,
Traite de la Physiologie.

86 THE QUESTION OF REST FOR WOMEN.

canvas with large meshes, mixed with muscular and nervous
fibres, the whole covered and masked by conjunctive tissue.
The characteristic muscular fibre cells can only be obtained
close by the surface of the membranous ligaments of the
peritoneum. Between the tzuo folds whieh form this surface
ive hardly find anything but cellular tissue ^ vessels, and nerves.
The muscular fibres are not easy to demonstrate ofi the child
or nulliparous woman. But during pregnancy, and for a long
time afterward, no more doubt is possible/* Three systems
of fibres are demonstrated. The first arise from the round
pubic ligament, and spread fan-shaped the entire height of the
uterus, interlacing with those of the opposite side. The
second come from the posterior surface of the uterus, and
form the ligament of the ovary. They do not terminate
abruptly at its internal extremity, but radiate into the stroma
of the gland, inclosing Graafian follicles in their meshes.
This is also admitted by Groher, but Waldeyer denies that
the muscular fibre reaches the follicles. He and Henle and
His' have found them forming sheaths around the arteries in
the medullary portion of the ovary, but not extending fur-
ther than the limit of the parenchymatous zone. The third
system described by Rouget should constitute the lumbar
ligament, which, however, is more difficult to demonstrate.
They are said to start from the lumbar region and uterus,
embrace the entire length of the Fallopian tube * and the
fimbriated portion, and by their contraction, draw the latter
down upon the ovary, close over the most prominent vesicle.
" This contraction results from the reflex irritation that has
been caused by the distension of the ovarian stroma when
the Graafian vesicles reach a certain degree of develop-
ment." This reflex irritation is propagated to all the mus-
cular apparatus of the internal genital organs. The ovario-
tubal fibres contract (ut supra), the contraction causes com-
pression in the muscular networks, and the blood is forced

* Described also by Ileiinig, Uer Katarrh, p. 3.

THEORY OF ROUGET. 8/

back from the ovarian plexus, distending the spongy bodies
of the uterus, until finally, under the increased pressure, the
bloodvessels of the uterine mucous membrane arc ruptured.
Hence the menstrual hemorrhage."

This theory has obtained an immense influence. Courty
observes that " by artificial erection of the uterus and ovary
on the cadaver we can demonstrate their true erectility, and
the part it plays in ovulation, menstruation, copulation."
These views again probably have had much to do with the
habit of considering menstruation as a local congestion,* and
unquestionably have done much towards confirming the
supposed analogies between menstruation and the rut, while,
on the other hand, they have themselves been guided by
these analogies.

It is unquestionable that the tissue of the ovary becomes
vascular at puberty, and smooth muscular fibre cells mingle
with conjunctive tissue of its stroma. The entire bulk of the
organ is somewhat increased in size. At birth it measures
about 1.3 cm. in length, 1-6 cm. in breadth, and 3 to 3.5
min. in thickness. In the adult female it is 3.8 c m. long,
2 cm. broad, and 15 mm. thick.' The few examples of
herniated ovaries that have been utilized for science, have
shown that the bulk somewhat increases during menstrua-
tion, and also the vascularity. This latter has been demon-
strated in autopsies.' But between these moderate variations
and the " erection " supposed to be demonstrated by Rouget,
especially the mechanism of the erection by reflex contrac-
tion of muscular fibres so delicate that, until they have been
developed in pregnancy, their existence can scarcely be
demonstrated, between these two sets of facts lies a wide
distance. We believe the following substantial objections
are to be urged against Rouget 's theory:

' Peaslee, New York Medical Record. 1876. Barnes, however, denies the appro-
priateness of this expression (Clinical Lectures). See below, Kundrat and Williams.
• Beaunis, Anat, Descriptive. • See p. 173 and p. 181.

88 THE QUESTION OF REST FOR WOMEN.

1. Even admitting (and we do not admit) that at each
menstruation the utero-ovarian plexus of blood vessels be-
comes as fully distended as in Rouget*s injections, such
injection would not of itself constitute an erection. Bouquets
of arteries, enclosed in the meshes of conjunctive tissue, and
trabeculae containing muscular fibres, exist in the spleen as
well as in the erectile tissues. Here also are all provisions
for sudden accumulations of blood, causing great distension
of the organ, yet no one would describe them as erections.
The distinction is of much practical importance, because this
term necessarily implies such intense excitation of certain
cerebro-spinal centres as must, for the time, interfere with
the activity of many others. .

2. Erectile tissues are everywhere external, developed
from the epiblast or embryonic fold of animal life ; while the
internal organs of generation develop in the hypoblast or
nutritive layer,. the primitive intestine. The predominance
in women of the internal over the external organs of genera-
tion is an indication of the predominance in them of repro-
duction over sexuality, not as Rouget supposes, of a transfer
of the seat of the sexual sense.

3. During menstruation sensation is either absent or pain-
ful. The cases where a conscious sexual instinct is awakened
at this period, are decidedly in the minority.* When painful
sensations exist, they are either in the form of cramps, burn-
ing, or weight. In the latter case the uterus does not rise in
the pelvic cavity, but sinks, which is manifestly opposed to
both the theory and experiment of Rouget.

I have noticed some exceptions to this rule. In the case
of an anemic and sterile woman, who habitually felt well dur-
ing menstruation, and the week preceding, but languid and
exhausted during the other two weeks, I found the uterus
retroverted, the examination being made at this latter time.
No local pain or discomfort was experienced from the dis-

* Bischoff in a famous memoir tries to evade and then explain this diflficulty.

THEORY OF ROUGET. 89

placement. On examining the day before menstruation, the
uterus was found to be in place, — literally erected.

4. The helicine arteries of the uterus and ovarian bulb
have long been regarded as a provision for pregnancy. It
has indeed been shown that their flexuosities do not, as was
supposed, disappear during pregnancy, and that the arteries
never become straight.* But the flexuosities permit of the
accumulation of a greater quantity of blood during a longer
time than would be the case, if the blood vessels were
straight. Hence an admirable provision for the nutrition of
the foetus. Moreover, as by the flexures in the cerebral blood
vessels delicate tissues, (in this case, those of the embryo,)
are saved from the shock to which they would be exposed,
were the great mass of blood required for their nourishment,
poured directly upon them. In a normal condition, the blood
that flows to the utero-ovarian plexus at menstruation, passes
off* as rapidly as it flows in." A stasis of blood in the parenchyma
of uterus or ovaries immediately induces symptoms which
are foreign to perfectly healthy menstruation. On the other
hand, when conception has taken place, the same accumula-
tion of blood will be effected without causing any feeling of
local distress. It is not at all uncommon even for women who
habitually suffer pain at menstruation, to pass six or seven
weeks of pregnancy without being warned by any pelvic sen-
sation of the physiological hypeniemia of the pelvic viscera.
In women who suffer from slight prolapsus or chronic uterine
congestion, the disappearance of the dragging sensations
about the loins that had become habitual, often constitutes
one of the first signs of pregnancy.

The writer recalls at this moment, four well marked illus-
trations of this fact. This shovvs that if the rapidity of circu-
lation through the ovarian plexus, be proportioned to the ex-

' Bames, as well as others, insists on .this fact.

• See p. 97. Williami, description of uterine parenchyma during menstni-
ation.

90 THE QUESTION OF REST FOR WOMEN.

cess of blood in it, no sensation results from the hyperaemia,
however enormous.

5. But the mechanism imagined by Rouget implies, not
an increased flux, but an increased stasis of blood, whose re-
turn through the uterine veins, is impeded by the contraction
of muscular fibres.' We think it is impossible, even through
Rouget's own descriptions, to admit the succession of phe-
nomena he so graphically and imaginatively describes. The
existence of planes of muscular fibre surrounding the ovary
in other animals, especially the ovipar?e does not afford even
a presumption that similar planes exist in women except in
a rudimentary form. Nothing is more common than to find
in the higher animal, and especially in man, rudiments of
structures more fully elaborated in lower animals. Rouget's
description in women is entirely of rudimentary muscular
fibre cells, and even these can scarcely be demonstrated ex-
cept upon the pregnant or recently parturient woman.
Again, Rouget insists on the fact that these fibres can only
be obtained near the surface of the peritoneal folds. The
lamina: that pass over the bulb of the ovary are too much
attenuated to exercise, by their contraction, any serious
compression of the vessels in the hilus. Yet it is to such
compression causing a reflux of blood towards the uterus,
that the author ascribes the entire " congestion ** that should
precede the menstrual hemorrhage. Moreover, an obstacle
afforded to the circulation at this point, should not com-
pletely dam up the pampiniform circulation, since as Rouget
himself points out, this plexus has three outlets, into the
pudic veins below, the uterine veins in the middle, and into
the ovarian veins only above.

We believe, therefore, that Rouget*s famous theory of
erection is not only unproved but untenable.

1. Because the disposition of blood vessels described by
him exists in relation to pregnancy.

2. Because autopsies of menstruating women have never

THEORY OF ROUGET. 9I

discovered a distension of these blood vessels in any way
comparable to that produced by his injections on the cadaver.

3. Because the sensations of the woman in the early weeks
of pregnancy, or during a normal menstruation, show that
the subjective expression of pelvic hyperaemia is very differ-
ent from that of stasis.

4. Because the phenomenon of erection does not depend
exclusively upon distension of cavernous tissues with blood,
but implies special phenomena of innervation, absent in the'
menstrual flux in the great majority of cases. It often hap-
pens in regard to this point, that the theory invents facts,
where the facts themselves would never have suggested
the theory.

5. Because erectile tissues, belonging to the sphere of
animal life, are developed from the animal layer of the blast-
oderm, or epiblast, while the generative intestine of the woman
is derived from the nutritive layer or hypoblast.

6. Because the muscular fibres in the peritoneal folds are
rudimentary except during pregnancy, are superficial, and
cannot be shown to compress the deep seated blood vessels
at all.

7. Because even were such compression exercised at the
bulb of one ovary, abundant outlets exist for the return of
blood elsewhere, so that an accumulation of blood by this
mechanism is doubly inconceivable.

8. Because the evidence which has been adduced to show
that Graafian vesicles may develop to their full size without
the occurrence of uterine hemorrhage, shows that such devel-
opment does not necessarily cause an irritation capable of ex-
citing reflux muscular contractions. This latter evidence has
been accumulated since Pfluger's Essay.

In considering the remarkable phenomenon of the men-
strual flux, two distinct questions require to be answered,
namely :

Why does blood flow to the uteri ovarian plexus, and why

92 THE QUESTION OF REST FOR WOMEN.

does it ^ow from the uterine mucous membrane. Pouchet
(see ut supra) by dissections of several domestic mammiferxl
showed clearly enough that during the rut, the uterine
mucous membrane was hyperaemiated. He even insists that
a certain amount of sanguinolcnt discharge takes place in
these animals, and explains its minute quantity in com-
parison with that of women, by the abundant space offered
by the lax tissues of the internal generative organs in which
blood may accumulate. This explanation has never been
accepted as completely satisfactory. Nor does an increased
tension in the uterine blood vessels, sufficiently explain the
hemorrhage, since here, as in all other organs, very great
congestion may exist without causing a rupture of the ves-
sels, even the capillaries. The imminence of this event, is
in proportion to the laxity of the tissues supporting the ves-
sels ; hence greatest in the brain, then the spleen, perhaps
last of all in the parenchyma of the uterus composed of dense
fibrous unyielding tissue. Hence, as will be seen, the ex-
treme rarity of hemorrhage below the level of the mucous
membrane.

It is only the internal surface of the uterus, where the
least facility exists for rupture of blood vessels, and this only
in one case, namely, if the blood vessels ramifying in the
endometrium are laid bare by the desquamation of its epi-
thelium.

As early as 1847, Pouchet already described such a des-
quamation. But the process has lately been much more
elaborately investigated in two memoirs, already become
classical.

The first is by Kundrat, and published in Strieker's Med.
Jahrbuchcr for 1873, (Heft. 2.)

The second by Williams, in the London Obstetrical Journal,
1875. Both memoirs are founded upon numerous autopsies.
We will quote freely from these investigations, beginning
with those of Kundrat as the earliest.

KUNDRAT'S RESEARCHES. 93

In a state of complete repose between the menstrual
periods, the uterine mucous membrane is only one millimetre
thick at the fundus and sides of the organ, and diminishes in
thickness towards the cervix and ostia of the tubes.

This mucous membrane is distinguished by a character-
istic conjunctive tissue rich in cells, and by the absence of a
submuncosa. The straight tubes constituting the glands, lie
side by side in the tissue, almost exclusively composed of
spindle-shaped or round cells, packed much like the glands in
the gastric mucous membrane. There are no muscular fibres
in this layer, but the conjunctive tissue stretches outwards
towards the muscular tissue. The glands are lined with
cylindrical ciliated cells which are continuous with those
covering the mucous membrane between the tubes.

The most essential difference between the mucous
membrane before and after puberty is in the glands. In a
seven months foetus, the membrane is 09 — 15 min. thick,
and contains no glands. These first appear at three to four
years of age, and then contain round cells. They are more
developed in the tenth year, and at twelve to thirteen begin
to branch.

During menstruation, the mucous membrane swells from
one millimetre to three or six millimetres in thickness, is soft,
tumefied, injected in spots or uniformly reddened. The
openings of the glands are enlarged, and a whitish opaque
mucus is poured out. The cells of the glands are enlarged,
(as those of the peptic glands during digestion) and there is a
multiplication of the round cells of the conjunctive tissue
stroma. The blood vessels are distended with blood. All
these appearances are confined to the superficial layer of
mucous membrane. In the same layer occur occasional ecchy-
moses. There is no proliferation of blood vessels.

These appearances are presumed to be characteristic of
menstruation, because found to coincide with the presence
of recent corpora lut^a in the ovaries. But their precise

94 THE QUESTION OF REST FOR WOMEN.

relation to the time of the dehiscence of the ovum is not yet
fixed. It can be concluded however that these alterations do
not begin and end with the menstrual hemorrhage. "In two
girls who died suddenly several days before the period, and
in others in which no recently ruptured follicle would be
found, the mucous membrane was already swollen to two and
one-half or three millimetres. We must believe that the
swelling begins a long time before the period, but reaches its
maximum at this time. It is so rare to find an absolutely
normal uterine mucous membrane, that we must infer the
period of repose to be very short.**

At the time of the hemorrhage, and until the return to
the normal condition, the cells are cloudy, and filled with fat
granules. This fatty degeneration involves the gland cells,
cells of interglandular tissue of the blood vessels, and the
epithelium of the surface, but is extremely superficial. " It
is my opinion," says the author, " that these alterations
develop independently of the haemorrhage, and indeed de-
termine it, because

"I. In spite of much more intense hyperaemia in the
endometrium of the pregnant uterus, no haemorrhage occurs,
showing that hyperaemia alone is insufficient to account for
the menstrual flow.

" 2. Haemorrhage docs occur in other physiological degen-
erations of the uterine mucous membrane, as at the end of
pregnancy. Should the decidua become fatty too soon,
haemorrhage will equally occur before term.

" 3. In the menstruating uterus, there is never any extra-
vasation, except in the superficial layer where the fatty
degeneration occurs. I conclude that the membrane degen-
erates because no vessels are developed to nourish it suffi-
ciently in its tumefied state, and that the superficial vessels,
thus laid bare, rupture, and permit the oozing of blood."

It is difficult to maintain the old theory that the uterine
hemorrhage coincides with the bursting of a Graafian follicle,

WILLIAMS' RESEARCHES. 95

for at that time the uterine mucous membrane is in the most
unfavorable condition for the reception of the ovum.

The swelling of the endometrium above described, implies
preparation for conception, and the retrograde metamor-
phosis is the consequence of the failure to conceive. " The
membrane occasionally thrown off in dysmenorrhea, implies
an exaggeration of the normal tumefaction and consequent
fatty degeneration."

Williams' researches confirm and extend Kundrat's con-
clusions. He found that the highest point of development
of the uterine mucous membrane was reached three days
before menstruation. It was then one-fourth of an inch thick,
covered with small white spots, shown under the magnifying
glass to be little pits, at the base of which were the orifices
of the glands. Thus the membrane was tumefied above the
level of the glands. No blood vessels existed in this tume-
fied portion. Still nearer to menstruation, the membrane
was dark red, thick, smooth, very soft, and contained innu-
merable blood vessels running parallel to the glands. But
of the two women on which this description is based, one
had succumbed to peritonitis. In four other cases, where
the relations to the menstrual epoch were not precisely
known, the mucous membrane of the cervix was found to
terminate abruptly just above the os internum in an excava-
tion. Above this, the endometrium was injected and tume-
fied, or else desquamated. The epithelium was in fatty
degeneration, and very superficial hemorrhages existed. In
two cases, where death took place on the fourth day of men-
struation, the desquamation of the mucous membrane above
the OS internum was complete. The muscular fibres were
bare, stained with blood, and covered by small shreds, com-
posed of round and fusiform cells, rod-shaped bodies like
nuclei of muscle fibres, and blood corpuscles. From numerous
points, blood exuded on pressure. In a case examined just
after cessation of flow, the membrane had begun to regen-

96 THE QUESTION OF REST FOR WOMEN.

erate in the lower two-thirds of the cavity. The upper third
was still covered with brownish shreds. The renewal of the
lining seemed to begin from the cervix. A little later, the
membrane was found renewed throughout, but epithelium
was still absent. Still later, the membrane was found com-
plete, but the orifices of the glands on a level with the surround-
ing surface ; hence the development was inferior to that ob-
tained three days before menstruation, and already described.

In reviewing these twelve autopsies, Williams remarks :
** It is erroneous to study the menstrual flow as a process
complete in itself, or to attribute it to a simple congestion or
a prolonged erection. It is only the terminal change of a
cycle of changes, which begins at the cessation of one men-
strual flow, passes through the developmental phases of the
mucous membrane, and ends with the cessation of the flows
next following. We are justified in affirming that there is
no period of uterine rest, but the organ is ever undergoing
those changes which either make it a fit receptacle for the
ovum \vhen impregnated, or which prepare it to carry off" the
ovum when impregnation has failed. If any one stage of
the month could appropriately be called a period of uterine
inactivity, it would be the bleeding period, for it is then that
the mucous membrane ceases to develop, and undergoes
fatty degeneration."

The author attributes the hemorrhage to two factors :

" I. The desquamation of the endometrium, by which the
blood vessels arc laid bare.

** 2. Contractions of uterine fibres, by which the blood is
forced towards these superficial vessels. The uterine walls
are found pale while the mucous and peritoneal surfaces are
congested. The increased quantity of blood in the uterus is
determined thither by the active processes going on in the
development of the mucous membrane, and is in nowise
allied to congestion. The flow of blood attains its maximum
at the time the proliferation is at its highest, that is, a short

TWO THEORIES OF OVULATION.

time before the catamenia appear. With fatty degenera-
tion, the flow is suddenly reduced."

For convenience sake we will contrast, in opposite col-
umns, the sum of notions in regard to the processes involved
in menstruation, that have been acquired in the last few
years by Waldeyer, Slaviansky, Grohe, Kundrat, Williams ;
and those deduced from the ovulation theory proper, as form-
ulated by Pouchet, Raciborski, Courty, Rouget, Pfluger, etc.

The Graafian vesicles and ova,
are either absent during childhood,
or exist in a comparatively rudiment-
ary state, undergoing no progressive
development.

The establishment of puberty is
principally characterized by the sud-
den development of the ovaries and
assumption of characteristic func-
tions in the ripening of ova.

Graafian vesicles and ova, indis-
tinguishable from those of the adult
female, are found in the ovary at all
ages after two years. From this
time no new vesicles are ever formed,
but those already existing, gradually
and successively develop, and hav-
ing reached a certain maximum
atrophy without rupture. (It does
not seem to have been ascertained,
whether the fusion with the vesicle
of Balbiani. and the fusion by appo-
sition with the epithelium of the dis-
cus proligerus, that, after puberty
are essential to the complete matu-
ration of the ovule, ever occur before
puberty. Probably not.)

The increase of size of the ovaries
during the three or four years pre-
ceding menstruation is very gradual,
nor is there any such development of
either uterus or ovaries as justifies
the term " building of a house within
a house,"* or local process involving
a great local drain upon the nutri-
tion. The essential change consists,
not in the size of the Graafian vesicle,
but in its increased vascularization,
and the secretion of fluid into its
cavity, leading to the rupture of its
walls and escape of the ovum.

* Clark, Sex in Education,

THE QUESTION OF REST FOR WOMEN.

To the irritation of the ovarian
stroma and peritoneal covering of the
ovar)', caused by the rapid growth
of Graatian vesicles, is due the afflux
of blood to the uteri ovjirian plexus,
(Pfluger) or the contraction of the
muscular fibres which causes an ac-
cumulation of blood in this plexus
by impeding its return. Congestion
and hemorrhage are the consequence
of ovulation and the dehiscence of
ova.

The effusion of scrum into the
Graafian vesicles, like the effusion of
liquor amnii into the cavity of the de-
veloped egg, is due to the increased
vascular tension in the blood vessels
of the ovarian bulb, and ultimately
of those ramifying in the perifollicula
layer of the vesicle itself. This in-
creased tension, and the increased
afflux of blood to the uteri ovarian
plexus is due to some condition en-
tirely independent of the develop-
ment of the ova, which condition only
obtains in the organism long after
the reproductive cells have learned
to grow to maturity. If not ovula-
tion, at least dehiscence of ova, is
not the cause but the consequence
of pelvic hyperaimia. The surface
of the ovary on which the follicles
rupture is not covered by peritone-
um, (Waldeyer) only a few out of the
immense number of Graafian vesicles
contained m the ovaries, ripen and
rupture at any one time, and as the
process of their complete develop-
ment is gradual, the periods of rup-
ture are necessarily intermittent.
This intermittence, however, far from
offering a type of physiological peri-
odicity, is one of the most irregular
of physiological phenomenas. It is
not to be compared with processes
associated with rhythmic movements
of the circulation, as sleep or wake-
fulness in the brain, digestion or re-
pose in the stomach. The successive
growth of the Graafian vesicles
strictly resembles the successive
growth of buds on a bough." It is
not even exclusively associated with

' The distinction between buds and seeds has much per]>lexed philosophic
botanists. We shall refer later lo ihe theories of Dc Candollc, Spencer and
Darwin. Dalton compares the Graafian to the dental follicles.

TWO THEORIES OF OVULATION.

The ripening and dehiscence of
ova occurs periodically at the epochs
of the rut in the lower animals, and
of menstruation in women. It is
this that constitute^ the essential
part of both processes, and these- are
strictly analogous to one another.
Menstruation is the rutting season
for women, the rut is the menstrua-
tion of lower animals.

the rhythmic flux constituting men-
struation, since vesicles do not
always rupture coincidently with this
flux, and may rupture when the flux
does not take place. The perma-
nent rise of tension occasioned by
the development of the ovarian blood
vessels at puberty seems to be suffi-
cient to secure the mechanical con-
ditions needed for the liberation of
ova.

In the lower animals, in whom
the sexual instinct exists exclusively
in connection with reproduction, the
period of the rut and the rupture of
Graafian vesicles does seem to
always coincide. At least several
vesicles are always found ruptured
in animals examined after this period.
There is no proof, however, that the
congestion of erectile tissues, and
the rupture of Graafian follicles,
stand in any causal relation to each
other, but rather that they are coin-
cident phenomena.

In women the sexual instinct and
reproductive capacity remain dis-
tinct ; there is no longer any neces-
sary association between sexual im-
pulse, menstruation, and the dehis-
cence of ova.

Reproduction is only possible at
certain times before and after the
menstrual period.

Reproduction, at no time im-
perative, is at any time possible,
though more probable before the
menstrual flow.

The menstrual hemorrhage is
the result of a periodical congestion
of the uterus, caused by the irrita-
tion of nipturing follicles in the
ovaries, and entirely subsidiary in
importance to the ovarian process. By
the afflux of blood to the great net-

The menstrual hemorrhage is
the climax of a series of processes
carried on in the uterus, quite inde-
pendently of the ovarian budding.
The afflux of blood to the uterus is
in obedience to an increased nutri-
tive demand made by the develop-

100

THE QUESTION OF REST FOR WOMEN.

work of vessels surrounding the
uterus, or by the stasis of blood in
them, the tension is sufficiently raised
to rupture the free vessels of the
endometrium, so that hemorrhage
occurs as in epistaxis.

ing mucous membrane, which con-
stantly increases in thickness, until
it has reached a maximum suitable
for the retention of an impregnated
ovum. The hemorrhage from the
uterus is the result of fatty degenera-
tion and desquamation of the mu-
cous membrane, that has failed to
receive the stimulus of impregnation
necessar)' for the maintenance of. its
heightened vitality. By this des-
quamation, blood vessels are laid
bare, and the resulting hemorrhage
is strictly analogous to that after the
fall of the decidua in parturition.

The vascular tissues of the uterus,
ovaries, and broad ligaments, are
species of erectile tissues, and their
periodical turgcscence constitute an
erection which should be expected
to render the menstrual period an
epoch of prolonged sexual excite-
ment.

The helicine arteries and bulbs
of the uterus and ovaries are dis-
positions for pregnancy, not for
menstruation. There is no proof
that these tissues are ever really
*' turgescent " in menstruation. In
normal menstruation the circulation
through these vessels is accelerated
in obedience to a nutritive demand
on the mucous surface of the uterus,
precisely as the circulation through
the muscular coat of the stomach
and intestines is accelerated during
digestion in obedience to an in-
creased nutritive demand upon their
mucous surface. But if an accumu-
lation of blood and stasis occur,
abnormal sensations are produced
foreign to healthy menstruation, and
indicating that some modification
of the healthy process has occurred.
All the processes concerned in men-
struation converge, not towards the
sexual sphere, but the nutritive, or
to one department of it — the repro-
ductive.

ANALOGIES BETWEEN MENSTRUATION AND PARTURITION. 101

The periodicity of the menstrual
flow constitutes its most striking
feature, and renders this process,
pecuhar to women, an extraordinary
exception among physiological phe-
nomena.

The periodicity of the menstrual
flow is not an abrupt interruption of
the ordinary physiological life. It is
the simple climax of a series of con-
secutive processes perfectly continu-
ous with one another. It does not offer
the sudden transition of the func-
tions of animal life, but the gradual
transitions characteristic of the func-
tions of vegetative nutritive life, to
which indeed it belongs.

The writer of the present Essay accepts the views repre-
sented by the second of the above columns. But it may be
shown that the explanation of the monthly hemorrhage
there given cannot be considered as entirely satisfactory.
The analogy shown between the menstrual decidua and that
of pregnancy, already suggests that some other cause for
hemorrhage must exist than the mere desquamation of the
mucous membrane. After parturition, many other condi-
tions are present. The walls of the uterus, full of blood, are
incessantly retracting and squeezing the blood out of those
enormous sinuses. The immense accumulation of blood in
the inter-ovarian plexus that exists at this moment, furnishes
abundant source for the hemorrhage. But at menstruation
a hemorrhage lasts precisely as long as does the lochial dis-
charge, /. ^., the sanguinolent, without the existence of any
such local accumulation. According to Williams, the uterine
parenchyma was found pale, and although other observers,
perhaps somewhat guided by their expectations, have de-
scribed a general hypcraemia of the organ, yet there is con-
fessedly nothing comparable with the turgescence of a preg-
nancy at term. Yet, as we repeat, the menstrual flow, and
the sanguinolent lochial discharge, are, when each is normal,
almost identical in duration and quantity. It is the men-
strual flow, however, which most often transcends the period
of four days. We are forced to conclude that the blood

102 THE QUESTION OF REST FOR WOMEN

comes from elsewhere than the " erectile tissues of the
pelvis ; " that the local process in the endometrium is only
the starting poiiU of an evacuation which is really drawn
from the general circulation. For, when the sanguinolent
discharge taking place from the uterus after parturition has
ceased, the organ still remains very much larger, and the
quantity of blood contained in it immensely greater, than is
the case in any menstruation. On the other hand, excessive
hemorrhage in menstruation, though often connected with
hyperaemia, dependent on subinvolution, fungous endome-
tritis, neoplasms, etc., is well known to be often independent
of these, and connected with causes affecting the general
system — as plethora or anemia of the vascular system, or
excitement or exhaustion of the nervous. A physiological
excess of blood in the uterus, therefore (as in the post par-
tum state), is in itself insufficient to sustain uterine hemor-
rhage, even when this has been initiated by desquamation
of endometrium, while in the absence of local accumula-
tions of blood in the pelvis, conditions affecting the general
nutrition arc capable of determining the most exhausting
hemorrhage.

This is the first fact which indicates that the menstrual
flux must depend upon some other causes than the local
processes going on in the uterus. " Were the hyperaemia
the direct cause of the hemorrhage," observes Gusserow,
'* extravasations of blood would be found much more fre-
quently in the deeper layers of the Decidua menstrualis." *
Vicarious menstruation offers an entire series of facts show-
ing, from another point of view, that the cause of menstrua-
tion is not located exclusively in the uterus. These facts
formerly attracted much attention, but since the prevalence
of the ovulation theory they have been thrown into the back-
ground. Yet all such cases, of w^hich Puech has collected

' Uebcr Menstruation and Dysmenorrha?. Samniliing. Klinike. Vortrage
Volkmann.

CARBONIC ACID AND MENSTRUATION. IO3

two hundred, are proof positive of the existence in the
female organism of a necessity for the periodical evacuation
of a few ounces of blood, — necessity so profound, that if the
ordinary mode of exit be barred by congenital smallness of
the uterine blood vessels, or defective desquamation of the
uterine mucous membrane, the evacuation will nevertheless
be effected elsewhere. In only one case did Puech find a
ruptured vesicle in the ovary at the time of the vicarious
hemorrhage. In the form of chlorosis described by Virchow,
associated with congenital smallness of the blood vessels,
this condition is not confined to the vessels of the pelvis, but
is generalized throughout the body. Here, therefore, the
amenorrhea is uncompensated by any vicarious flux.

We do not propose, in this place, to examine the various
theories that have been aclvanced in the most remote and
the most modern times, to explain the menstrual flux by
some necessity of purification, or of elimination from the
blood of morbific material. This theory, originally derived
from the Jewish views on the subject of uncleanness, was
supported by Aran by means of the researches of Andral
and Gavarret on the respiration. These physiologists, as is
well known, asserted that during menstrual life women
habitually exhaled less carbonic acid by respiration than do
men. Aran suggested that the deficiency was made good
by the carbon evacuated with the menstrual blood. Dr.
Clarke rather vaguely admits a necessity for " elimination "
of somethings as one for which special provision must be
made during the time of menstruation. The reviewer of
Dr. Clarke, in the American Journal of Medical Science,
enlarges upon the same idea.

Rabuteau * has reexamined these experiments of Andral
and Gavarret, and aflfirms that in them, not sufficient atten-
tion has been paid to the time in relation to the menstrual
epoch. That during the period comprised between the five

* Gaz. Hebd. 1870.

104 THE QUESTION OF REST FOR WOMEN.

or SIX days that follow the cessation of menstruation, and a
day or two before its return, the elimination of carbonic acid
was found the same in the woman experimented upon as in
man. But during menstruation, the carbonic acid diminishes,
because from the loss of blood corpuscles the amount of
oxygen introduced into the blood, and consequently the
organic combustions, are diminished.

The temporary diminution in the elimination of carbon
from the lungs, while indicating a temporary diminution in
the energy of respiration and in the nutritive processes of
disassimilation, is very far from indicating an accumulation
of carbonaceous material in the blood. " The amount of CO,
extracted,*' says Ranke,* " depends upon the metamorphosis
of tissues. It is increased by muscular movement, but more
so by any increase in the hydrocarbons of the food, and in
comparison with these, all other circumstances, as age and
sex, are of very little importance. Part of the CO^ eliminated,
passes out of the tissues in a solid state in saline combinations
in which the venous blood is richer than the arterial." ' Ac-
cording to this, either venous or capillary hemorrhage, such
as constitutes the menstrual flux, wojild compensate, were it
necessary a defective elimination of CO, by the lungs.

It does not therefore follow, however,, that in amenorrhea,
unless dependent, as is exceptionally the case, upon a local
impediment to evacuation by the uterus, there is the least
danger that hydrocarbons will accumulate in the blood. For
with the above exception amenorrhea is always accompanied
by a defective nutrition of tissues, lowered vitality of cells,
hence a diminution in the absorption of Oxygen and corre-
sponding diminution in the formation of CO, "The

most important circumstance, observes Pfluger, determining
an increased absorption of O, is an increased vital activity in
one or more organs.**

The condition of vital activity or of general nutrition that

* Gnindzuge der Physiologic, p. 465. 1875. • Ibid, p. 471.

NUTRITION AND MENSTRUATION.

105

obtains during the menstrual period is of great importance
for the question discussed in this Essay.

We have devoted so much space to the examination of
this so called ovular theory of menstruation, because it has
been predominant in inducing the conviction, that during the
time of the hemorrhagic flow, the general nutrition and vital
activity of the woman must be lowered.

This view has not been universally held, nor is it only
held by the advocates of the ovulation theory, but also by
those whose attention is especially fixed upon the fact of the
periodical hemorrhage. Each group may be subdivided into
two on this point, according to the different interpretation
given to the same facts. Thus :

During menstruation, nutrition
and nervo muscular action must be
lowered.

I. Because the local processes
effected in the ovary and uterus are
so complex, and involve such an ex-
penditure of vascular, nervous and
nutritive force, that the rest of the
body must become temporarily bank-
rupt.

Or on the other hand :

2. Because the loss of blood by
the catamenial flow acts like any
other hemorrhage to anemiate the
blood, lower the tension of the vas-
cular system, and by the loss of
blood corpuscles interfere with the
absorption of oxygen, with formation
of COi, and of urea, in a word with
the assimilative and disassimilative
processes of nutrition.

The menstrual period should be
one of increased vital energy.

3. Because the entering upon
active functions of the ovaries im-
plied by the rapid maturing and de-
hiscence of the Graafian vesicles
affords a powerful stimulus to the
entire nervous system, like the shock
from an electric battery :

I06 THE QUESTION OF REST FOR WOMEN.

4. Because the hemorrhage
which when restrained to normal
proportions is not followed by any
of the consequences of accidental
hemorrhajje implies that the nutrition
of the woman has reached a high
maximum, in excess of her individ-
ual needs, and affording a surplus of
material that must be utilized or
thrown away.

Our commcntar>' on the above would be as follows :

I. The increased nutrition of the ova in the ovary in the
cases, far from uni\'ersal, where this coincides with men-
struation and the increased development of the mucous
membrane of the uterus, do divert from the general circulation
an amount of blood comparable to what is diverted during
the functional activity of many other organs. Into all active
organs blood streams in consequence of nerve action, and
the blood current is accelerated.

In rabbits at rest the locomotive apparatus contains 36.6<<
of the blood mass ; but in rabbits in motion, 66;©. The mass
of blood in any organ is in proportion to the metamorphosis
of tissue in the organ. There is a coincidence, therefore, of
activity and hyperaemia of one set of organs with repose and
anemia of another.*

In animals killed during digestion, the entire digestive
apparatus is found reddened and richly injected with blood.
The stomach, intestinal mucous membrane, and pancreas,
show this change most markedly ; the liver is slightly en-
larged." ** There is such an opposition between the circula-
tion in the muscles and the digestive, that we are enabled to
dissipate congestions of the liver by means of muscular
exercise."

I am not aware of any experiments upon women anal-
ogous to those made by Ranke in animals, by which the

* Ranke, Loc. cit. p. 374.

LOCAL ACCUMULATIONS OF BLOOD. IO7

amount of blood circulating in the uterus and ovaries during
menstruation could be estimated. For reasons already set
forth, neither the forced injections made by Rouget on the
cadaver, nor the intense hyperaemia observed on the external
genital organs of animals during the rut, can be relied upon
as a basis for this estimate. But the size of the organs,
relative to the mass of the body, indicates that, until the
beginning of pregnancy, the diversion of blood, even to so
rich a plexus of vessels as the uteri-ovarian, cannot be as
extensive as to the liver, gastro-intestinal tract, or brain. In
rabbits, Ranke has estimated the usual distribution of blood
thus :

Spleen 0.23 per cent, of the whole mass of blood.

Bones 8.24

Heart, lungs, great vessels. . , . . . 22.76

Muscles in repose 29.20

Liver 29.30

Brain and cord 1.24

Kidneys 1.63

Skin 2.10

Intestines 6.30

It is certain that the amount of blood determined to the
pelvis during menstruation (before the flow) varies extremely
in physiological and pathological cases. In analyzing pain-
ful cases we shall find a marked contrast between the cases
where no pain is experienced, or where it only comes on in
the shape of cramps during the first day or two of the
hemorrhage, and those other cases where the flow is pre-
ceded for several days by sensations of weight, dragging,
fullness about the loins, indicative of pelvis congestion.

We shall have occasion to speak of these cases again. It
suffices here to insist on the fact, that as they differ, to how-
ever slight a degree, from perfectly healthy cases, they can-
not be considered to illustrate the type ; and that wherever
the sensation of weight is absent, trifling, or only just pre-
cedes the flow that relieves it, we may affirm that the pelvis
blood vessels have not been distended by an amount of blood
suflficiently considerable to seriously deplete the rest of the
system.

I08 THE QUESTION OF REST FOR WOMEX.

The appearance of the mucous membrane during men-
struation has been frequently compared with that offered by
others in acute catarrhal inflammation (Courty, Beigel, Vir-
chow, etc.). The term suggests a pathological condition,
which, however, lies in the term. If, as is certainly true (see
our statistics), this process can be accomplished in 53 per
cent, of cases without the least interference with the con-
sciousness of well being, it is evident that the resemblance
with inflammation is deceptive, since quite a slight degree
of inflammation of this same membrane always involves dis-
tinct suffering. Expenditure of nervous or formative force
involved in the rupture of follicles and growth of the decidua,
ceases to appear a brusque robbery from the sum total of
the individual force, when these processes are seen to be so
gradual in their evolution. Although only one Graafian fol-
licle (in the human subject) be ever ready to rupture at any
given time, yet it is admitted on all sides that the develop-
ment of different follicles at various grades is incessant. Still
more gradual (if possible) has been shown to be the growth
of the endometrium, which is scarcely inactive during eight
or ten days, if at all. Nor are these days those, except in
persons affected with endometritis, on which the woman
habitually feels in the best health, for that is during
the week immediately preceding menstruation, when the
tumefaction and injection of the membrane reach their
height.

It is true therefore that the vital activity of the cells of
the ovary and uterus proves the necessity for an amount of
vital force in the organism superior to what would be required
by an individual having no corresponding organs.

But as this demand for vital force is, as we have shown,
continuous, it implies a permanent provision for its existence
in the organism, and not a succession of temporary revolu-
tions of that organism's resources. A body more rich in
organs, an organ more rich in cells, consumes absolutely

MENSTRUATION AND VITAL ENERGY. IO9

more material than one poorer in organs, (Ranke Loc. cit. p.
19.) In other words, it is constructed on a higher type.

2. The best commentary to be made upon this statement,
is the counter statement under the fourth head, showing that
the menstrual flux does not resemble in its phenomena or in
its effects any accidental hemorrhage.

3. We have a certain number of facts to be related further
on, which indicate that the period of menstruation may be
one of increased vital energy and especially of increased
mental force. But we cannot find in the ripening of the
Graafian follicles, any cause for an increased stimulus to the
nervous system.

It is the presumed analogy between menstruation and the
rut, and the theory that the starting point of the whole
menstrual nisus was to be found in the bursting of this tiny
vesicle,* that has theoretically invested a nutritive process, so
minute in extent, however mighty in result, with such an
immense influence on the nervous system. The peritoneal
wound (shown by Waldeyer not to exist, since the peritoneum
does not cover this portion of the ovary,) which excited such
luxuriant compassion on the part of Michelet, should by this
time be relieved of the responsibilities laid upon it. We
think indeed that the female economy can be shown to nor-
mally experience a stimulus, more or less powerful in con-
nection with menstruation, but there is nothing to show that
this is derived from a sudden and fermentative evolution of
nerve force in the ovaries.'

* " AH facts agree to prove that menstruation is the consequence of the ovarian
process on which depends the development and rupture of the Graafian vesicle.
The menstrual hemorrhage is an accident due to the insufficient resistance of the
capillaries of the endometrium, when congested at the time of the development
of an ovarian vesicle." Liegois, Traiti de Physiologie. 1869. Pp. 262-264.

*Chereau, Maladies des ovaries.

The extent to which the ovaries have succeeded to the uterus, in the capacity
for inflaming the scientific imagination, may be gathered from these words of
Virchow. " The woman is only woman on account of her generative glands "

no THE QUESTION OF REST FOR WOMEN.

4. These remarkable peculiarities of the menstfual flow,
which to the majority, of observers learned or simple, have
always distinguished it from accidental hemorrhage, demand
an explanation if any theoretical conclusion can be arrived at
in regard to the effect of menstruation on the working capa-
city of women. It is certain that in the case of any other
hemorrhage of far less amount and duration, the most com-
plete rest of body and mind would be claimed as a matter of
course. It would not be necessary for instance, to forbid
peasant women from treading out grapes in a wine vat, dur-
ing an attack of epistaxis, as it has been found necessary to
do during menstruation, not for the sake of hygiene but
cleanliness. Their own bodily discomfort would suffice to
preserve the proprieties.

If of the two modern theories, periodical or reflex irrita-
tion from the ovaries, or fatty degeneration of a uterine
decidua rendered useless by the failure of conception, neither
serves to completely explain the menstrual hemorrhage, we

(ovaries). All the peculiarities of her body and mind, of her nutrition and nerve
activity, the sweet delicicy and round contour of her liinbs, the characteristic
sha))e of her pelvis, the development of her bosom, the gentleness of her voice,
the beautiful lustre of her hair, and the scarcely perceptible down on her cheeks;
then again, the depth of feeiin;^, devotion and fidelity, in short all the feminine
qualities that we admire and ht^nor in the true wuman, are only a consequence of
the ovary. What wonder then if i)y the periodical dehiscence of ova. phenomena
occur which indicate the general parlicijiatiim of nutrition and nerve force ? I
will remind the practical physician of teething, a process which consists in the
|>eriodical reproduction of parts of much less significance, and which neverthe-
less i?? accompanied with the liveliest disturbance of nutrition and nerve force.
(Her puerperale Zustand. Das Weib, and Die Zellc, 1848. P. 751.)

We think in regard to this language, the remark of Puech, who comments
upon it, is justified: "Certainly if brilliancy of thought, if elevation of language
occuj)ii.'d the place of arguments, we must incline before this panegyric, but in
physiology as in medicine, the authority of the master is dominated by the
auihority of facts. In view of the observations rclateil in this chapter, [showing
the per>istcnce of feminine qualities in the absence or after the extirpation of
the ovaric'^.J the idea of Virciiow regarding their role is not only gratuitous, it
i;> illogical." Des ovaries, de leurs anomalies, 1S73, p. 125.

PLETHORIC THEORY OF MENSTRUATION. Ill

are led back to the older theory, which has prevailed half as
many centuries as the ovulation theory has years, the theory,
namely, of an excess in women of nutritive force and mate-
rial, which, when not utilized in reproduction, is expended
in menstruation. Wagner, whom we have already quoted as
a champion of the ovulation theory, /. c, as considering " the
characteristic cause of menstruation to reside in the ovaries,**
adds, " Nevertheless, we are far from contesting a special
physiological significance to this hemorrhage. ... The
blood which is evacuated at the time of menstruation contains
all the essential constituents of normal blood. . . . What-
ever peculiarities it offers are explained by the external con-
dition of its evacuation. We should therefore with difficulty
be justified in considering the menstrual blood as useless
material. It is a surplus acquired in the mechanism of indi-
vidual life, and whose formation is effected by the entire
mechanism of the body. It is completely analogous to the
formative material which elsewhere is employed for the
development of the embryo, for the nutrition of the ^gg, etc.
The surplus, which could with impunity be removed from
the individual existence, which' indeed must be removed
under penalty of manifold disturbances, serves to cover in-
creased expenditures. . . . According to our opinion,
the separation of the menstrual blood is nothing else than
the separation of a superfluous formative material in a char-
acteristic form. What in other cases (/. e. in oviparous
animals) leaves the material body as the substance of the
ovum, here passes away as blood, in the same form in which
it originally is brought to the ovum.

On this account is the menstrual flux limited to the
mammiferae. For in these animals the ovum is so small that
after its formation a large amount of formative material is
left over. Again, were the mammiferae egg-laying animals
like birds, then doubtless must the tgg contain all the nutri-
ment required by the embryo. Thus, in a human being, the

112 THE QUESTION OF REST FOR WOMEN.

egg must contain as much nutriment as is absorbed from the
maternal body during ten months* gestation. In that case,
an cg<^ could only ripen ever>' ten months, and the possibil-
ities of conception would therefore be extremely limited.
But in fact, the material which we have imagined concen-
trated upon a single rut, is divided over ten successive
periods of rutting, at each of which conception is possible.
The striking minuteness of the mammalian ovum, therefore,
may be considered as a means whereby the possibilities of
fecundation are multiplied, and thus indirectly, the fertility
of the mammiferai heightened.**

Reproduction, without a previous provision of reproduc-
tive material and of formative force, is unknown throughout
the vegetable and animal kingdom, and is indeed inconceiva^
ble. In plants, nutritive material accumulates regularly at the
nodes of the stems, and the degree of development attained
by the bud springing from the nodes, is proportioned to
the space between them or the intemodes. So has Wagner
again shown that the number of offspring of any race of
animals is in exactly inverse proportion to the weight of off-
spring at a birth, and this proportioned to the length of
gestation. ** Genesis, under every form,*' says Herbert Spen-
cer,' *• is a process of negative or positive disintegration, and
is thus essentially opposed to that process of integration
which is one element of individual evolution. Negative dis-
integration occurs in those cases where, as among the com-
pound Hydrozoa, there is a continuous development of new
individuals by budding from the bodies of older individuals;
and where the older individuals are thus prevented from
growing to a greater size. Positive disintegration occurs in
those cases of agamogcnesis where the formation of new
individuals is discontinuous ; and in all cases of g^mo-

genesis. . . . The degree of disintegration becomes less

•

marked as we approach the higher organic forms. Among

* Principles of Biology, Vol. I., p. 2 1 6.

GENERATION AND INDIVIDUAL NUTRITION. II 3

the higher animals there is no case in which the parent indi-
viduality is habitually lost in the production of new individ-
ualities. To the last, however, there is of necessity a greater
or less disintegration. The seeds and pollen grains of a
flowering plant are disintegrated portions of tissue, as are
also the ova and spermatozoa of animals." Again (p. 224),
" Agamogenesis continues so long as the forces which result
in growth are greatly in excess of the antagonistic forces,
while conversely, we find that the recurrence of gamogenesis
takes place when the conditions are no longer so favorable
to growth. . . . Very high nutrition in plants prevents
or arrests gamogenesis." De Candolle says,* " The indefinite
development of boughs which do not flower, favors the birth
and growth of a great number of nutritive leaves, which
tend to increase the aggregate, and to deposit here and there
stores of nourishment suited to favor new development of
germs or flowers. The termination in flowers tends to
deprive branches of the development of nutritive organs, and
to consume the nourishment stored up in the branches,
stems, or roots. In caulocarpal plants, the flower is small,
and only consumes the nourishment stored in its own
peduncle and immediate supports. These are perennial
plants, trees, and shrubs. In rhizocarpals the flowers are
more numerous, in proportion to the strength of the stem,
and exhaust all its nourishment, so that it dies down to the
root. These are perennial herbs. In manocarpals, the flow-
ers are still more numerous, and exhaust the root as well as
the stem. These are annual or bisannual plants." Darwin'
says of sterile cultivated plants, with double flowers, rich
seedless fruit with largely developed organs of vegetation,
that there is in them a saving of nutriment and vital force,
because the sexual organs do not act, or act imperfectly. In
his treatise on sexual selections, passim^ the author insists

' Organographie Vegetale, 1827, p. 230.

• Variations of Animals under Domesticity, Vol. II., pp. 131, 172.
8

114 THE QUESTION OF REST FOR WOMEN.

on the secondary sexual characters of brilliant plumage and
various appendages in the male of various animals, especially
birds, that seem to serve as an equipoise to the excess of
reproductive force in the female.*

* A. B. Blackwell (Sexes throughout Nature) has justly pointed out that these
secondary sexual characters are much more strongly marked in polygamic birds,
and where food is easily accessible, so that the male is not compelled to exert
himself even for the indirect nutrition of offspring.

SECTION IV.

EXPERIMENTAL.

ON the hypothesis that the menstrual period represents
the climax in the development of a surplus of nutritive
force and material, w^ should expect to find a rhythmic
wave of nutrition gradually rising from a minimum point
just after menstruation, to a maximum just before the next
flow.

The traces of this rhythmic wave should be measured by
the consumption of oxygen, the excretion of CO, and of
urea, by the tension of the arterial system, the vital capacity
of the lungs, possibly also by the dynamic force of muscles.
We have attempted to make a few of these measurements.
The following tables show the results of daily measurements
of urea in the urine of six persons for a period of one, two,
or three months.

The urea was measured by Liebig*s volumetric method.
The whole quantity of urine passed in twenty-four hours was
collected, and the specimen analyzed was selected from the
whole amount.

Ii8

THE QUESTION OF REST FOR WOMEN.

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120

THE OUESTION OF REST FOR WOMEN.

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THE QUESTION' OF REST FOR WOMEN.
NO. III.

Due ■;)

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TABLE NO. III.

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99.6

99-7

gcslire liead-

99-

98.4

99-1

99.H

3ot

3oi

ache rrom over-

994

98.8

99.6

99-8

hen (ing.

98.4

98.

93.6

98.7

8S6.41

39.251

Wcnl 10 counlry

99.1

93.6

99-»

9S.4

98.

i».

99,1

99-

98.8

99.5

99-S

93.5

98-3

9S.a

98.3

99,6

98,6

99-3

995

93.4

98.

98-71

99-7i

ISI1.4I7

26.651

»iV

Returned this A.

99-4

■J9-

99-7)

99-7t

98.4

97 B

9S-S

98.6

39i

set

99'

93.4

99-4

99.6

9a.3j

'I7-9

99-4

99 4

141B.356

31.91c

'AS

Headache.

99'

q8.6

99.21

99-Si

Sludied ime.

98.

93.3J

9S.4

98.7J

9S.S

■J9.2I

99.34

98.

98- <i

3»

1419.162

36.896

99-5

9S.6

999

99-9

98.5

g8..i

98.7i

99-6

99.1

98.9

99-S

99-5

98.9

98.=4
98.8t

99-

35l

3'i

9"5-957

25.1S8

a,^

99-5

99')

99.

98.5

991

99,2}

37
35

3ii

1181.880

31.910

"'•

■98.V

99.

'98 v

"99.VI

99.

'99-V"

99.6

99-4

3>i

"37-559

15-595

99-71

99.5

100""

100.3

93.4

.,8.

9S.6i

98-51

[063.693
iisa.333

27,655

38.SoB

■98.35'

97-9

"^.6"

"ga.V

995

99-

99-9

99.8

98.3

98.4

99.2

99-5

98.3

98.5

98-5

98.

99-S

99'6

945-504

3 '■('74

3,'A

Ahm,

THE QUESTION Ol-' REST FOR WOMEN.
NO. III. (CoHtmiiid.)

Due -ri

se.

. T.„,^.,„„. „

Dyn.
Klght

mic.

o'clk

o'dk

Mouth

A.il...

V.«Ln..

Kecluni.

Lift.

4o'clk.

..ocU.,

■>8.4

98.

9S.6

98.71

July i6»

yb.aj

'W-2i
9S.5

^:6*

331

" 17*

6fi

9IJ.

9S,4

9s 6

99-

" i8

9-.f.
97. 7i

'W-9

'W-9
9S-3

381

" 19

9S.3

9.).a

9.,.2

fl6i

7B
9S

60
61

■y3.Vi

93-71

99-5

99,6

ya.

97-7i

98.5

98.6

" 33

60
54

66
86

98.7;

9'*-5

99-21

'J9-2

3S
34

34l

S3
74

63
74
60

■<aV

■9S-4"

'■w-Vj

W-Vj'

993

'»■

99-6

'99-8"

y».5

97.8

93.5

9S-5

33
34

32
28

64
66

W-

'9S.6 '

99-;i

100."

9S.5

98.

')9

■' 35

;t;

9S.S
97-9

9S.71

9.^6

98.S

" =7

" 23

74
76

99.2

99.6

99-9

79
80

70
63

1/J.3.

■98.7;

"i^.V

i»i.""'

9J.b

9^.2

99,3

99-2*

" '9

" 30

'■ 3'

Aujf. I

7S
66

1)9.2 i

9S.9

'W-5

99-5

33
30
35

3''

27
361

30J

74
So

74
60
So
66

99-5

99.

9-/6

w-a"

w'a"

*9»'7l'

■99.2^'

99-2

99.4

99.

100.4

;;.;..;j'

'».2

9S.5

9971

99-7 S

lib

(16

'isV

"9S.V

99-5

99.C

•' 3

9>).0 1 93.3
9S.S 1 98.

99."
'W.3

■/J-71
'J9-3

" 4

V)-4 1 99-2

■>S.O 98.2 1

99.

0<)-ai

" 5

... .1

98.S 98.21

9)-

'■ 6

<j.j.2 1 g*.6

9.),6

'W-''

■'

■W. 1 98.5

9.j.aJ

W=l

■■ 7"' 70 , ■ ■

■W.2j 1 ■,>

>„.6

'»■

3ii

, 1 -w-s

'i--A

Vj.

'W-4

- S-' (-D 1 72 ',■).

9S,4

'W5

'H-5

\ 'J-i-5

9S.2I

'W->

" ■)• ''li 1 Tt- W-^i

9S.S'

99.7 1

6.-8

341

, 'H-n

9».

99.21

<W-2l

99-4

99.

99-5

m-i

TABLE NO. III.
NO. III. ■

Dyni

Lcf.

r.,m^

LT™.':

Moutli.

.xm..

\-.gin.

R«.™

Ti^

Remiikf.

993

99.1

995

99-5

■J3.4

98.

99-

94.

590.940

19 79*'

3tt

Headache.

9Q.5

98.5

98.3

93.7i

9S.

9S.S

99.S

12 26.300

26363

^A*.

99-t

98.4

9"J.

99.

g8.ai

97-5

08.1

99. r

590.940

16.150

','A

99-

98.6i

993

99.6

98.2J

97-S

93.1

9S.4

753-448

14-MO

3,Vo

99'S

98.71

99-5

9S.

98.

98.5

98.4

•H-^l

98-7J

<»-S

99-51

99.6

93.3

99-

99.

9 '5-957

25.188

*,V.

99.2J

9S.fil

99-5

99-7i

98.S

98.21

98.5

98-5

99-4

98.9

99.5

994

98.

9a.

93.5

98. S

36
34

32
26

1048.918

30.41B

=i'A

'98.5'

97-9

'9S.V'

■93.61 ■

99 =

99-'

999

99.9

98.=i

90.

98.S

9S.6

975-05'

23401

aAS

99.S

98.9

",)S.ii

99.1

99.3J

ti8l.S8o

»a45S

'AS,

'w's '

999

"99.61 ■

98.5

*98-3

99."

99.si

34
36
36

ioai.598

1521.670

25.114

33476

'99-

■98.5'

99.

99-

Slept very lilUe.
Ai work men-

'.'.'.'.'.'■

Wily anxious.

99.1

■98.8 ■

99.7

Im."

Consli]>aIed.

99,1

9S.7

99-

'Asl

'98:71

99-

1 100.625

25-S64

*lVo

Conslipated.

99'5

994

99-7!

99.8

Cold and rainy.

1^1

98.

9(>.2

98.

£l!

9^-81

'^'■'j

lOO.Z,

99.1

99^91

341

31 i

1248.360

26.839

>Aft

99.S

99.

997J

99-9

99-

9S.3

99-3

99.2

36!

3'!

99,6

99.

98.9

98,5

99-

99-' i

1034,145

»5.8S3

',h

995

9S.3

99-71

99-9

yl/-«u. this even-

.•^^

93.5

99.

98.9

291

: 226.200

28.815

JiVo

ing. no pain 10

98.

"gS."

■98-V'

■98.V

99.

98.5

99.ai

99-31

3«1

■

.011.9S4

»4.793

«,'A

126

THE QUESTION OF REST FOR WOMEN.

NO. III. {Continued)

A. M.

Date '75

Aug. II
" 12

" 13

" M

" 15
•* i6

" i8

" 19
" 20
.. 21

Pulse.

o'clk

t«

" 24

M 25

'• 26

" 27

•• 28

" 29

" 30*

•' 31*

•Sept. i^

66
66

64
64
72

• •

68
66

74
80

78
63
60

70
66
66

64
70

u'clk

74
84
72
76
80

• •

78
78
76

76
74

Temperature.

Mouth

993

98.

99-4

93.7J

98.3
<;9-4
98.

99.

98.5J

99.

9^5
99.2

99.
W-5i

99.
98.6

99.

99-4

98.5

99.7

98.9
99.6

99.

99-2 J

99.4

98.5

9<)-7j

9S.5

99.

98.4

99-5
9S.5

99. 2 J

9S.2J

99-3
9S.5

'9^."4*
99.

Axilla.

98.7}

98.

99.

98.5

98.

Vagina.

99.5

99.

100.

99. 2 J

98.5

99.5

99.

98.9
100. 1

<W-2
99.8

99.3
99.6

992
99.3

99-3

ICX).I

99-2J
99-7i
99-5

98.8

99-5

98.5
100.

99 5

99-5
9<;.

99-5
99.

9<>-5
98.7
99-5
98.7

9S.5
99-7}

Rectum.

99-5}

99.

lOO.I

99.2J

9S.4

99-3
98.5
99-5

Dynamics.

Pulse.

Right.

Left.

•

4 o*clk.

ixo'dk.

• •

• *

• •

33}

• •

29}

31}

29}

• •

29}

25}

« •

29}

27}

37}

.■ABLE NO. III.

NO. in.

» Tempentui.. ••

D,...,„.

&.To^.

Grais

Per

RcmarLs.

Mautb.

A mil.

Vi«™.

R«....

RiKhl.

L.n

5S.Ji

gB.ai

98.3*

9S.4

34
34
33i

36
35
35
3'
33J
34
33
33

33
33
33i
37J
33i

3E>

30
29
jg
30
30
30
361
=81
39
27

2Bi
37
37i
30
30

»7!

856.663

1255747
595.336
797.769

B56.863

1359-lf'a
1368.719
989-834

IOK.S4S

620_4B7
886.410
738.675
827.316
1418.256
945504
■Sgo.940
753.448
531.846
620.487

21.421
18.836
I.-.54Sr
37.^31

aa.7o6

25.834

1S.468

25.840

33.785
■7-363
18.614
21.421

10.6S2

31.373

23.637
19. 50]

2I/D96
1967a

2. .59.)

3tS,

'li.

3A
3A

3 A

^A
=iS

'A
'A

.;8.

99-

99'

98-5

995
gS.s

99.3

99.

9t.5
100.5

995

i«..li

9»S

99-i

W-S

99.7

99.6

99.9

99.6

128

THE QUESTION OF REST FOR WOMEN.

• JO

^ • CO

M •

• • M <

- -t •

m <

. O • '

. . o ■

. CO

• CO . '

> • ►^ ■

> r>i

• w>

_ • ,

t * «

* m

!!*!«.

! «^ I !

1 w

«*

^ .

1 I I t I I ** !

, ^ , ,

; ; N ;

, «^

: «^ :

t ©^ : N

• • •

CI CO

O • M

«n • GO

o
«n

ciciciciciciciciMC«et
«* wcicicici- WW-

►v ^

»/> >0 oo r^ o i^

GOOOCOCO* OO- OOC^o

C» C^ C^ C" c^ c> c^

1^ O r* c* C^ O^

• •*•••

GO oo oo Q ^ CS

C* O* O* O C* O*

CO ^ «^ •t ro

oo CO CO CO OC CO

c* o o c^ c^ c^

cif*;>-rwr»c^« ^ T^

oooooooooooo^ods odoo
C^ o^ o^ ^ ^ o^ o* ^ o*

«>

u
3

u
V

!>• CO

O « O CI GO Q

00 t^ CO l>* O oo

c«

< .<-•

too -tf^'fOei M C*
CI « CI CI CI e« CI M M

ei- - * NMCiciei

C« M

in •f

CO oo .

oo oo 00 o6

o* c* c^ o*

8: t

i^ OO i>« oo 3

OS c^ c^ a*

rf 00

r* t>. 00 r^

Cs C* 0» OS

OO CO

O OS

•

•t

N ,

r>.

r^ -

Cl .

I>. *

I" CI

GO t^

•I

r«i oo Cs O M CI

1^ M 1^ CI Cl CI

*rt «a « « « «

to -t
CI CI

in O
CI CI

r* CO

CI CI

c> o

CI CO

M e« en •*

-=* 2 S «

TABLE NO. IV.

129

"I §

4> 3 W

•^G

M «J C

4> .• 5

•^ .2

_ X

'IS «

.to ••

1J2 lalS w*

:S : :sS •• ::« -R ^ •? ^ ^ -g :

q
oo

mo r«c< mOO tnO

• ••••••■•

OoOvO O C^cO'TC^^o
eowweo««neiMi-i

O Tf GO 00

• • • •

« w « ri

^ :

! 00

•

■ g^

•

CI
CI

•

**>

. 00
CO

• GO

M
■ C^
. 00

. ?

N4
W

^
*•

«•
W

m
CI

>•

«•
«

«
«

^
«•

<•
«•

f to

•8

V
*•

•
•

m
CI

00
) CI

CI CI

m \0

M C4

•

-t

8: S:

«•
«•

>•

^
>•

; 8

\ GO

•

00
0*

•

w
«

•

00*

00'

to -J-

CO CO

00*
0*

«
w

«
«•

«
«

^
«

<•

GO
00

V
*•

>•

•

CI
CI

cn
CI

c«

«•
«•

CO
CI

«
«

«
«•

•

<•
«

*•
«•

^ 1"

«•
<•

*•
<•

•8

00
CI

» oo

«•
«•

m
CI

w
••

<•
«

C» »n CO O I" N -t"

. • * * ■ — i * * •

Q^ Q O* 5* 5* ^ ^ ^ ^

Q\ 5 Q\ ^\ ^S ^^ C^ w^ ^K

Tf CI -r CO -t-

OS o* o^ o^ ON o* O V* w O^

tn "t" CO

CO 00' CO

o> c^ o^

-*}• CO -r ^

oo 00 00 CO

Qs O* 0> O^

•t- CO "t c< CO r^ Tf

00" CO 00* 00 «) 00 OC CO CO CO
O^ C^ O^ O* ^^ O^ O* G^ O^ O*

O -t-oo woo woo O -rO-

GOCOO I'-^OO t^vOOOOOOO*

O -t O
00 CO 00

t/> >o t>> 00 o^

^ t.

CI CO T M^ O r^ 00

M C< CI

CI CO -t »n O 1^ CO

M CI C4 CI CI CI CI

I30

THE QUESTION OF REST FOR WOMEN.

> :•

'/^

a
S

i
0^

«< a-
c X

4> "-J .3

c
o

^rf

-2 cS

••*

•^ «= -2

•
•
•

-1

•*

• •*

f«^

•t

r>.

•t

-t

. tr\ '

. o '

: 3

!>.

»n

t^ <

• r>i •

C»

f«^

. Ox .

• en

•

-t

', «*^ '

•'^

t*l

«n

, ^

m tnOfcoOf^NO

C^ r>.N^cociinc^«»r

en Ocnini-iCi«n«C^

• • ■•••••

M cor>.oc*QO»^ooc

O fncir^O«-iOOC^

\n r^coo»>»"^»nr*tn

' t^

: o

»^ !

; «>

• M

«« !

• f

: T :

! "*■ .

• o

. o .

: 8 :

• M

. e/5

• o

. GO

• t

', "^ I

*•

•

t^ -

C«

■

«•

CI -

•

■

i-i in

-il- in

"* W

tn Tf en

§; =

•

3 § §; =

g: g '

S^ g ^

_• _• _•

C7» O* cS

e«

•

fl«

•

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cr z

s CO s :

<» S 5

: oo s

: oo oo

H
<

c»

o* c^

cc CO o CO * t^ oo

oo oo

fn .
ci -

w tn

r*
w

O in
c< CI

i>« CO tn
CI c( m

M n d

^ ^ §

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g S S g:

C^ CO

■8.

■y.

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t^ -

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— ' c

TABLE NO. IV.

131

5 o w

•

-."©

•
•

«
•

•
•

•s

•
•

Hs-S

-S

5|2

5fe

^is

•

«n

^ •*

•^

00
in

•^ O^inO^M tnO^oo
inl>«t^Cl tnOO O*

»>.0»U>CO^COvOCO

cJ«ncic^i-«Mcici
cicncncncic«c»c«

?%n vO
in

C4 C«

ft ?

m CI
c« ri

O
in

-f M CO •-"

e*^ OO W Q

• •

o C^

g- S

•J- « t^

c*^ O^ in

q o q^

c*^ d CO in

o vo t^ r^ vO

N ^ N CO

vO O -^ CI

2 g^

1^ in tn M

« « « •• CO

- - * - w

t>» m >0 * >0

W W « "^ CI

-t- r^ in to **• CO -t-

c^ o c^ o c* o^ 5*
O^ w^ o^ o* c^ o^ o^

^^ ffs o^ O^ •
w* C^ o^ c^ •

« CO N N t-i to

OOOOCOCOCOQOCOCO

o^ ^^ o* c^ ^^ ^^ o^ o^

t ' '

in CI

cc co'

CO O -
O CO -

00 00 CO GO 00

^ - » • , CO «

^ w *■

« « « «

<•<•««. d "

• - - - - in «
- - - - - C4 *

vO
CI

•
<• ^ <«

« ^ ^ «

« « ^ ^ •

CO •t in rf to to

^? ^^ 5* 5^ ^^ ^^ ^
W* ^^ ^^ 0^ 0^ w^

•

8 8 =

in
in tT CI

On 0* ^ * "•

c^ c* 0^

CO M

CO* od CO

0\ o^ o^

M N- CI m

CD 00 oo d* 3 O^
C^ O* O^ C\ Qs

00 CO ::

o* o^

« 00
- 00

CO "

= 5

d 0* CO

CO "

«
w

in \0

t^ CO

2" 8

CI
CI

to -t- in
CI CI «

« « w

« >• •

r^ 00

CI M

CN Q

CI CO

M
CO

I30

THE QUESTION OF REST FOR WOMEN.

> ".

•

C X

rt o .

U9C c

4> "-J .3

•a

2 S o

3
C/3

:§

^lo

-»•©

• -»•©

•

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• ->•©

-5

-Z

-2

^-s

•?

•s

: SS

: ^

• ^

• -^

. Tf

«>

•r r^

■f

-t

\n \0

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' o

: «8

M GO

CO m

. r^

CO <

> t^

O GO

»n

-1 c»

. «o -

. Ox .

I-. o

•r CO

: o ;

. o

: «^

CO «

«o w

: w

. ^

CO
CO

vO
in

tn O "H oo O CO N

!>• n CO N »r> O^ M

O CO »n iH w CO N

CO r^ cS Q> CO M CO

CO N r>. o •-• o O

r^ CO vO »>• "^ »n r*

, r*

! o .

»^ .

I «>

oo !

"* !

I ^

! "«■ I

• o

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• o •

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. >c

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. vO

vO
CO

•

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C5

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CO .

^ 1*

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w -

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136

THE QUESTION OF REST FOR WOMEN.

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137

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138 THE QUESTION OF REST FOR WOMEN.

A glance at these tables taken from six persons, during two
or even three months, shows that the average amount of
urea excreted was considerably in excess of the amount stated
by Rabuteau. His figures vary from 14 to 22 grammes daily,
while in our tables the amount rarely falls below 20 grammes,
is much more frequently 25 or 28, and in a great many cases
rises to 35 or 38. The individual variations are quite marked.
Thus No. II shows quite a high range, No. V, when however,
the analyses do not run over so long a period, has a lower
average. This first difference between Rabuteau's table and
ours is, we think, to be explained by this fact, that his single
case was a woman living in a hospital, perfectly quiescent in
mind, and not too active in body, while our cases are all
students subjected to considerable mental strain. Any in-
crease of this strain caused an immediate increase in the
amount of urea.* Thus in No. I, after twelve hours of severe
mental and bodily fatigue, 68.585 grammes of urea were ex-
creted. The amount of urine as well as the per centage of
urea were both exceedingly increased. On another occasion
in the same table mental anxiety was followed, (July 16) by
a rise in the urea, from 25.838 grammes of the day before to
35«345- O*^ the next day, complete relaxation being taken,
the urea fell to 19.943 grammes. In No. Ill, after mental
anxiety- and sleeplessness, the excretion of urea rose from
25.114 grammes to 33.476 grammes (July 31st). In No. IV, '
on July 27th, the amount of urea rose to 46.152 grammes,
coincidently with mental and bodily exertion. The highest
amount reached on any other day than this, from June 17 to
August 31st, was 37.583 grammes (July 3d). In No V, a
week, during which the urea varied from 15 to 19 grammes,
(and a fraction) was spent in sewing (July 14-20,) on the 22d
study was recommenced, and the urea rose to 23.401 grammes.
In No yi, the occasions for exertion, all midwifery cases,

' Wc have recently examined the urine of a woman suffering from incipient
melancholia, and mentally inactive, and the excretion of urea remained at 14 or
15 grammes daily.

SUMMARY OF ANALYSES OF UREA.

139

vary extremely in the amount of urea. Thus the first, when
forceps was used, only 18.614 grammes were said to be ex-
creted ; on the second occasion, 28.365 ; on the fourth,
23,932; on the fifth, 31.497 : and on the sixth, 32.720. It is
possible that the exertion involved more expenditure of
muscular than mental force.

The amounts of urea excreted on any given day of the
menstrual period, (the days of the flow are marked with an
asterisk in the tables), vary' very much. Thus in No I, the
large amount of urea excreted on June 19th, coincided with
the first day of menstruation. At the first day of the next
menstruation (July 16), the amount was only 25.838 grammes.
The rise on the second day again coincided with the mental
anxiety as before noticed, and the fall the third, in con-
nection with an afternoon of relaxation, took place in spite
of the continuance of the menstrual flow. In No. II, the
first menstrual period, (July 2-4) contains higher amounts
of urea than at any other period on the table (41.129), but
the amount on the second day (37.642 grammes) is equalled
on several non-menstruating days, and the amount on the
first day (31.724) falls below that of several other days.

Perceiving that these individual figures would be of little
value, we have compiled a summary from the tables, showing
the sum total of different days.

No. I.— EXCRETION OF UREA DURING

5 days preceding
menstniation.

5 days of menstrua-
tion.

5 days following
menstruation.

5 days in middle

inter menstruation

period.

134.870 Grms.

133.542 Grms.

118.485 Grms.

121.731

No. II.— EXCRETION OF UREA DURING

istm.

3 days before
menstruation.

97.020

3 days of
menses.

110.495

3 days succeeding
menses.

106.367

3 days in middle
intcrm. period.

90.580

I40

THE QUESTION OF REST FOR WOMEX.

2d m.

3 days before
menses.

3 days of
menses.

3 days succeeding
menses.

3 days in middle
interm. period.

86.180

94.667

75.285

78.150

3d m.

3 days before
menses.

3 days of
menses.

3 days succeeding
menses.

79.612

88.388

81.020

No. III.— EXCRETION OF UREA DURING

3d m.

2 days before
menses.

2 days of
menses.

2 days succeeding
menses.

• •«••• •

52.692

53608

90.257

4th m.

3 days before
menses.

3 days of
menses.

3 days succeeding
menses.

3 days middle
interm. period.

57.198 Grms.
(diarrhoea.)

65.592

60.275

79532

2d m.

3 days before
menses.

3 days of
menses.

3 days succeeding
menses.

3 days middle
interm. period.

82.058

77.833

65.548

93.

No. IV.— EXCRETION O*' UREA DURING

istm.

5 days before
menses.

5 days of
menses.

5 days succeeding
menses.

146.429

144.955

122.023

2d m.

5 days before
mouses.

5 days of
menses.

5 days succeeding
menses.

5 days in midst of
interm. period.

152.046

137.169

155.577

117.254

3d m.

5 days before
menses.

5 days of
menses.

5 days in midst of
interm. period.

142.139

120.142

132.797 Gniis.

SUMMARY OF ANALYSES OF UREA.

141

No. v.— EXCRETION OF UREA DURING

4 days before menses.

4 days out of 6 menses.

4 days succeeding menses.

•

125.247

87.457

70.522

No. VI.— EXCRETION OF UREA DURING

istm.

2 davs before
menses.

2 days of
menses, (days)

2 days succeeding
menses.

2 days middle
tnterm. period.

38.288

31.939

37.614

31.094

2d m.

5 days l)efore
menses.

5 days of
menses.

5 days succeeding
menses.

5 days middle
interm. period.

138.057

134.506

122.073

127.499

3d m.

5 days before
menses.

5 days of
menses.

5 days succeeding
menses.

5 days middle
interm. period.

153.998

156.281

The most constant relation discoverable from these tables
is that between the amount of urea during menstruation and
during the days immediately following. Out of fourteen
cases (distributed among six persons), the urea diminished
quite markedly in ten. In two cases there is a slight increase,
and in two (the 3d month of No. VI.), and the 3d of No. III.,
the urea is not estimated during the post-menstrual week.
The percentage of the diminution after the cessation of the
flow is extremely variable. Estimating the difference as the
percentage of the amount eliminated during the menstrual
flow, we have in one case 3 per cent., in two cases 8 per
cent., in one 2 per cent., in one 11 per cent., in one 15 per
cent., in one 19 per cent., in one 20 per cent., in one 25
per cent., and in one 29 per cent.

In five cases out of the eight in which this detail is

142 THE QUESTION' OF REST FOR WOMEX.

specified, the amount of urea immediately after menstruation
was less than the average for the corresponding intermen-
strual period ; in the other three it was more.

The relation of the amount of urea excreted during men-
struation to that excreted just before, varies with the persons.
It is diminished in No. I. (one analysis), in No. IV. (three
analyses), in No. V. (one analysis), and in No. VI. (three
analyses); also in one out of three analyses of No. III. In
two analyses of No. III. it is increased, and in the three
analyses of No. II. There seems reason to suppose that the
individual tendency predominates ; still, in the majority of
the cases (nine) we can say that the urea is diminished during
the flow ; in five increased. We have said that in the decided
majority of our cases, the urea during menstruation was
more abundant than during the week immediately following.
In comparing it, however, with the amount excreted during
a corresponding number of days at intermenstrual periods,
we find, out of fourteen cases, in four it is not specified, in
one the quantity is the same, in four it is less, and in five
more.

No conclusion can be drawn from this limited number of
cases, where the variations are much greater than in the
other proportions. This is probably owing to the fact that
the amount of urea is always influenced by a variety of cir-
cumstances, among which menstruation only counts for one.

The most general result to be deduced from these tables
is the following.

During the few days preceding the menstrual flow, the
: excretion of urea is generally increased above the average at
intermenstrual periods (seven cases out of ten specified). In
the majority of cases (nine out of fourteen), the urea dimin-
ishes from this excess during the flow, while in a minority of
cases ('five out of fourteen), it continues to increase. The
alternative of increase or diminution seems to depend on
peculiarities generally persistent in the same individual.

AVERAGE OF PULSE AND TEMPERATURE.

143

In the great majority of cases, the urea decreases markedly
after the cessation of the menstrual flow (ten cases out of
twelve specified) ; and in the two cases in which an increase
seems to have existed, it was much slighter than the usual
decrease.

The average of pulse and temperature have been exam-
ined in the same Avay.

TABLE No. I.— P. AND T., FIVE DAYS AVERAGE.

Pulse.

Rectal Temperature. A. M.

Before.

During.

After.

luterm.

Before.

During.

After.

Interm.

99.36

99.26

99.78

99.18

TABLE No. IL— P. AND T., AVERAGE THREE DAYS.

Pulse.

Rectal Temperature. A.

1st m.

Before.

During.

After.

Interm.

Before.

During.

After.

Interm.

70}

98.75

98.58

99.25

ad m.

721

99.16

98.91

98.50

99.00

TABLE No. III.— P. AND T., AVERAGE THREE DAYS.

Pulse.

Rectal Temperature. A.

adm.

Before.

During.

After.

Interm.

Before.

During.

After.

Interm.

70}

70J

99.8

99.36

99.23

99.73

3d m.

65i

99.6

99.43

99.50

99.43

4th m.

65t

• •

99-53

99.66

99.23

• • • •

144

THE QUESTION OF REST FOR WOMEN.

TABLE No. IV.— P.

AND '

r., AVERAGE FIVE DAYS.

Pulse.

•

Rectal Temperature. A . M.

ist m.

Before.

During.

After.
80

Interm.

Before.

During.

After.

Interm.

98.60

99-33

99.12

98-40

2d m.

80.8

73.2

81.6

9932

99.25

99-5

9938

3d m.

96.4

• «

81.6

100. 1 1

101.23

• • • ■

9938

TABLE No. v.— P. AND T., AVERAGE SIX DAYS.

Pulse.

Rectal Temperature. A. M.

Before.

During.

After.

Interm.

Before.

During.

After.

Interm.

731

76J

99.58

99.29

99.33

TABLE No. VI.— P. AND T., AVERAGE FIVE DAYS.

Pulse.

Rectal Temperature. A. M.

Before.

During.

After.

Interm.

Before.

During.

After.

Intenu.

2d m.

• •

99-

98.8

98.6

3d m.

99.86

99.58

• • • •

The results from these tables do not justify either the
description of a " febrile condition " occasioned by menstrua-
tion (Allan Thomson), or a ** lowering of puLse or tempera-
ture" (Rabuteau), as constant conditions. In Nos. I, II,
and III, the pulse during the flow was a few beats lower
than during intermenstrual period ; but in No.s. IV, V, and
VI, it was about as much higher. As regards the tempera-
ture, in the ist, 3d, 4th, 5th, 7th, 8th, 9th, and nth analyses
(eight out of twelve) the temperature was diminished during

COMPARISON OF TEMPERATURES.

145

the flow, but very slightly, from .07 of a degree to .44 —
never, therefore, as much as half a degree. In one case the
temperature was exactly the same during the flow as during
the preceding week; in one there was a rise of .13 of a
degree; in one of ij^ degrees; and in one the temperature
was decidedly febrile (101.23), rising 1.12 over that of the
preceding week.

In eight cases out of eleven in which intermediate tem-
perature is given, we find that the premenstrual temperature
was higher than the average existing between the periods.
The excess ranges from .07 to .86 of a degree.

The following table compares at a glance the two sets of
variations :

Excess Premenst. over Menst.

8 CAses out of la, fractions of a degree.

.07

.17
.20

• . *

.25
.26

.27

.28

.44

Excess Premenst. over Interm.

8 cases out of k, fractions of a degree.

.07
.16

.17
.18

.20

• • •

.50
.73

This shows, as indeed can be seen by reference to the
previous tables, that the diminution of temperature observed
during the menstrual flow is hardly ever (three cases) to a
point below the average, but only below the level of a tem-
perature that had been attained just previously. That is to
say, the temperature rises from one to eight-tenths of a
degree during the week preceding menstruation. It falls
gradually during the flow, but in the majority of cases does
not even then reach the normal average.

An attempt has been made to estimate possible variations
in muscular force in relation to menstruation.

This estimate is imperfect because only based upon trials
made with the hand dynamometer. In the comparative
estimates of muscular force in men and women, as they have

146

THE QUESTION OF REST FOR WOMEN.

been made by Quetelet,* the results obtained by this instru-
ment were supplemented by others obtained by Regnier's
dynamometer for measuring the strength of the muscles of
the back and loins. During menstruation, however, it might
be expected that the force of this set of muscles would be
diminished, out of proportion to that of the rest of the body.
The following averages have been obtained with the
dynamometer. We have made from the general tables a
summary of a few days, only taking the test with the right
hand and for the morning.

TABLE No. I.— DYNAMOMETER TEST, FIVE DAYS.

Before Meust.

During Menses.

After Menses.

Intermcnst.

291

28i

28J

26| or 27

TABLE No. II.— DYNAMOMETER TEST, THREE DAYS.

Before.

During.

After.

Intermenst.

1st m.

30.16

29.66

33.5

2d m.

36.5

34.16

3d m.

35-5

TABLE No. in. DYNAMOMETER TEST, THREE DAYS.

Before.

During.

After.

Interment.

1st m.

• • • •

26.66

26.16

32.83

2d m.

32.83

33.5

34-16

34.5

3d 111.

32.66

• • • •

33.16

4th m.

33.66

31.33

• • • •

' To which we shall have occasion to refer.

COMPARISON OF TEMPERATURES.

147

TABLE No. IV. DYNAMOMETER TEST. THREE DAYS.

Before.

Durioj^.

After.

latermenst

1st m.

25.2

25.8

25.2

25.

2d m.

24.4

26.

28.8

. *

3d m.

25.8

26.

• * •

• •

TABLE No. V. DYNAMOMETER TEST, THREE DAYS.

Before.

During.

After.

Intennenst.

29.16

28.5.

30.16

28.33

In the sixth case, muscular power was tested by lifting
weights, calculated from the tables. For five days we have —

TABLE No. VL

Before.

During.

After.

Intennenst.

1st

255 lbs.

253 lbs. average.

245 lbs.

260 lbs.

275 lbs.

264 lbs.

260 lbs.

292 lbs.

288 lbs.

Out of fifteen examinations on these tables, the muscular
strength during the menstrual flow was less than that during
the preceding days in seven cases, was increased in seven, and
in one, was exactly the same.

It is Table VI, where the test was made by the lifting of
weights, that the diminution was most uniform, notwith-
standing a constant increase in muscular power during the
three months of practice. We consider this the most reliable

148 THE QUESTION OF REST FOR WOMEN.

table, as the results from the dynamometer, except for com-
parison between the right and left hand, are too much influ-
enced by the degree of skill, the force of the hand and wrist
muscles, not always proportioned to that of the rest of the

body, and finally by the most transient conditions of health.
Transient fatigue is excluded, since the test was always applied
at 8 A. M. The full tables show, however, that the evening
test was by no means inferior to the morning.

The last measurement of rhythmic waves of nutrition or
vital force, that we have been able to make, relate to sphyg-
mographic traces of the radial artery. Before considering
these traces, we will quote from Landois,* certain laws, that
are illustrated by our cases or serve to explain them.

1. The dicrotic elevation {Ruckstoss elevatioii) is so much
the greater, the less, (ceteris paribus) the tension of the ar-
terial walls, and vice versa (5th Law, p. 192.)

2. By increase of pressure, in consequence of a hindrance to
the outflow, the elasticity elevations on the descending curve,
rise higher in proportion to the summit, (7th Law, p. 199.)

3. By very low tension of the arterial walls, the elasticity
elevations may entirely disappear. This happens for instance,
when there is a great diminution of the blood, from a hemor-
rhage or exhausting disease (8th Law, p. 200).

4. In one and the same artery, the number of elasticity
elevations increases with the degree of tension of the arterial
wall.

5. Increased pressure has for consequence a stronger
primary pulse wave and more marked elasticity elevations,
without an essential increase of the dicrotic elevation (p. 125.)

6. Since increased activity of the heart increases, ceteris
paribusy the pressure in the arterial system, it causes a rise
in the level of the entire curve.

7.' The primary- pulse wave rises when the pressure in the

* Die Lehre vom arterien Pals, 1872.
' This law as seen, is not from Landois.

SPHYGMOGRAPHIC TRACES. 149

artery is increased by an increased mass of blood, whether
this be caused by expiration (p. 193), by inspiration of com-
pressed air,* by compression of a large artery (p. 195) by
Morbus Brightii (p. 197.) Diminution of the mass of blood
lowers the tension and increases the dicrotism.

According to Waldenburg, if the level of the entire curve
rises, while the height of the primary pulse wave diminishes,
and the summit becomes more round, the fullness of the
artery, and the tension of its walls are both increased. If
the fullness and side pressure are diminished the dicrotism
is increased, the elasticity elevations diminished, the curve is
lower, and each pulse wave smaller.

The following traces have been taken with Mahomed's
sphygmograph, in which exists a mechanism for varying and
accurately estimating the degree of pressure exerted on the
artery by the lever of the instrument. We have in nearly
all the cases, taken the trace at four degrees of pressure
marked respectively 2, 5, 6, 7 ; pressure 5 gives the best
average.

No. I is taken from a young woman of rather delicate
appearance, but in good health, and who never suffers any
inconvenience during menstruation. The premenstrual pulse
is given for two successive months. The first ranges from
December 22 to December 24 (two traces) ; the second from
January 14 to January 22 (four traces). The intermenstrual
pulse is represented by the two traces of January 7 and
January 11, respectively ten and fourteen days after cessation
of menstruation.

On the fourteenth day after menstruation (January li)
the trace is as follows : primary pulse wave (line of ascen-
sion) moderately developed, summit rounded, showing a
fair degree of fullness of artery and resistance in its wall ;

* Waldenburg, Die Pneumatische. Behandlung, pp. 28S, 290.

ISO THE QUESTION OF REST FOR WOMEN.

dicrotism scarcely perceptible, elasticity elevations only occa-
sional; the entire curve elevated and arching above the
starting point ; these last three characters all indicating good
tension and well-filled arteries.

On December 22 (first premenstrual trace) the primary
pulse wave (ascension line), marked 5 and 7, is decidedly
higher than the corresponding lines on January 11. The
summit is more prolonged, even flattened, in line 7, showing
considerable increase in the tension. In line 5, elasticity
elevations appear distinctly. The rise in the general curve
is not more marked for line 5, and does not appear very
decided in line 7, until this is compared with the similar line
in January 11. On that day the artery seemed unable to
resist so high a degree of pressure, and the curve sank instead
of rising. Moreover, the height of the line of ascent was not
greater with 7 than with 6 or 5. But three days before
menstruation the line of ascent is much higher under a strong
pressure than under one a little weaker. All these characters
indicate a considerable increase in the tension of the artery,
and increased resistance of the wall. Were the resistance
only increased, the line of ascent would • be lower, even
though the height of the general curve remained the same.

On December 24, one day before menstruation, the curve
is a little more elevated, the summit more rounded, while
the line of ascent is more oblique than on either December 22
or January ii, but not so high (compare lines 5 and lines 6
on the three days).

There is therefore still greater fullness of the blood vessel
and resistance of its wall (pulsus plenus). For this month
we have no trace during menstruation ; but two days after
its cessation we have a very peculiar trace. The pulse was
100, the line of ascent brusquely vertical, increasing in height
with each degree of pressure, and at 5, 6, or 7, much higher
than in any other trace from this subject. The summit,

Dec 5MK. t>ul«e icxv M<nM* ccMcd Dm. sMi.

TDK QU8STU1S' QT R^T FOR WOUEK,

I ihrrr: cltKracten all inilicatmg gf.

, ami dor* iioi aj :

lead

and
thou_

nJcra strong
i'-. >f chamctcn
icrcdw: m tliv Icdmimi (it ihe arlvty,
of the WaII. Were ihe n:;iUta»cc
of asccni would 'b^ tower, even
general curve rcmaiBOi the mmc
day before mecmtruadon, tbc curve
nded. while

the Htw *^ uticcnt is more ubUi^uc than un either December 32
m JuMiMy 1 1, but nor so Ii%K (cotn^iarc tines J and line* 6

linj; menstruation; hat iWQ'
,1 \crv p«uliar inict. The- p

I oTtcr
4vsn

^Hl

Dec. 22d. J days be(ure menses

Dei;, 23c!. {confinufd)

Dec. a4th. Menstruation.

Dec. 30th. Pulse 100. Menses ceased Dec, 28th.

Jan. id, Piil>e too jlh .iji iftc

Jan. t4th. 9 days bdotc n

^^H

No, I ifontinued')

Jan. 2d. Pulse loo. 5lh day afn^i

SPHYGMOGRAPHIC TRACES. 1 51

instead of being rounded, forms an acute angle with the line
of ascent, especially noticeable with pressure 7. The dicrotic
elevation is more marked; the elasticity elevations have
altogether disappeared. These characters indicate dimin-
ished tension in the arterial walls, combined with increased
energ>'' of the cardiac systole. The young lady felt perfectly
well, and could refer to no circumstance capable of explain-
ing this remarkable alteration from her habitual pulse, altera-
tion not repeated on the following month. Three days later
the pulse is still 100, but the line of ascent in the pulse-waves
has fallen markedly (compare lines 5 and 6 for the two days,
December 30 and January 2). On January 14, nine days
before the next menstruation, the fullness of the artery is
much increased, as indicated by the marked rise in the curve,
especially at pressure 7.

The line of ascent is again higher, and the summit more
rounded than in the intermenstrual trace. But the dicrotic
elevation is more perceptible, and there are no elasticity
elevations, while the pressure, resulting from fullness of the
artery, is therefore increased, the resistance of the wall seems
to be somewhat diminished. On the i6th these characters
were less marked ; on the 21st, two days before menstruation,
the curve sinkSy and all the characters indicate a lowered ten-
sion of the radical artery. On the 22d, however, the tension
rises again, and (line 7) elasticity elevations appear. Finally,
eighteen hours after the menstrual flow (January 23), the
trace shows greatly diminished fullness of the artery (curve
low, line of ascension low, summit little marked), while the
tonicity of the walls is not diminished, there being no marked
dicrotism. The same characters persist on the day after the
cessation of the flow.

No. II is from a young lady of robust appearance, but
the member of a gouty family, and herself suffering occasion-
ally from dyspepsia, acne, sciatica. Very little pain at men-

152 THE QUESTION OF REST FOR WOMEN.

struation, but great weakness, although the flow is not
excessive. On this account, No. II habitually remains on
the sofa during four or five days. She is in easy circum*
stances, and not compelled to any exertion, otherwise it is
probable that this would be found more possible than it
appears. Of this case, unfortunately, I have no intermen-
strual trace, but two sets of traces for menstrual periods.
On December 28, just after the cessation of the menses, it is
evident that the pressure is low. The curve sinks, and the
ascension line is very short. The resistance of the arterial
wall is not especially diminished, or else the signs of such
diminution (vertical ascension line, dicrotic curve, peaked
summit) are absent, owing to the diminution in the contents
of the artery, and in the energy of the cardiac systole. The
trace on the second post-menstrual period (January 21) alto-
gether resembles this first, except under pressure 7, the
ascension line becomes more vertical, and the dicrotic eleva-
tion is more marked. In the other lines, a trifle more full-
ness in the artery seems indicated by a little more roundness
of the summit. On January 10, four days before the first
menstruation, a striking alteration is observed. The curve,
though not high, is sustained without sinking ; the ascension
line is nearly vertical, and much higher, but the summit is
tolerably sharp. This shows increased force of the heart's
action, without a corresponding increase in artetial tonicity.
It is noticeable that the height of the ascension line increases
with the degree of pressure applied up to 6, but with 7 it
falls below that of 2.

This is the reverse of what is observed in No. I, Decem-
ber 30. It seems to imply that the vigor of the cardiac
systole would not be sufficient to so greatly develop the
primary pulse wave if the resistance of the arterial wall were
very great. At the same time the dicrotism is little marked,
and elasticity elevations appear. On the whole, therefore,
the tension is raised by intra-arterial pressure. January 12,

No. II

"■

[ IJcr jSA

Mc,.«»>.i— *

_ j^n. loUi.

4 duys licforc mcaan

ii^^H

^^^^^^^^^^^ J u 1 7 dnj-i' Iwfore memo

No. II. '^•''

Jut uth. i«t A*y

No. II. iconttHued).

SPHYGMOGRAPHIC TRACES. 1 53

' two days before menstruation, these characters persist, ex-
cept that the primary pulse wave is smaller with pressure
2, and much increased with pressure 7. Dicrotism is more
marked, the elasticity elevations less so, showing that while
the pressure remains the same, the resistance is somewhat
lessened. On January 13, the day preceding menstruation,
the resistance is decidedly diminished, the pressure remain-
ing nearly the same ; the angle of the summit is quite acute,
the dicrotism much more marked. On January 14, the first
day of menstruation, the intra-arterial pressure falls, but the
resistance is somewhat increased, as indicated by a more
oblique line of ascent, and a more rounded summit. On the
fourth day of the hemorrhage (January 17) the pressure is
reduced to the minimum, being lower even than on the two
post-menstrual days, December 28 and January 21. The
curve in trace under pressure 5 sinks notably, and 6 and 7
are very much less distinct than on two days after men-
struation. There (line 7), though the resistance is low, as
shown by the dicrotism, the primary pulse wave is tolerably
developed, but on the 17th it is extremely small.

No. Ill exhibits the pulse of an extremely robust person,
sanguine temperament, vigorous health. The menstruation,
however, generally came only every five or six weeks, but
then was normal in quantity and unattended by incon-
venience. It is noteworthy that this person, though only
about thirty years old, was very fat. The premenstrual
traces were taken on the ninth, seventh, and second day
before menstruation (December 22, 2*4, 29). The trace on
January 16, ten days after menstruation, is the nearest we
have to a complete intermenstrual trace, to serve for term
of comparison. The primary pulse wave is fairly developed,
the summit rounded, but dicrotism is very distinct. We
should infer arteries tolerably well filled, but with not very
resistant walls. Such are precisely the characters to be
expected in well nourished, plethoric fat people, in whom

KrsT FOR wot*

musci'
bef-

Wh.. "■

Won- wii

fm iMh to (Uyt^U'f mvnics,

t^r. \l, • « . < i|k:<:;«I Jan. na : tmn^ Jan rSth,

No. IV. {i\mrfn/ii--f.\

Be. 3..t.

After Excitement. Menses experted \)itc. 31SI ; arrived Jai

2 —— —

__r~

-—:— rrr;

Feb. »i8t. Mensfs expected : arrived lo days later.

Der. 14th. 4th dixy menses.

l)i;r. a7[h. Menses ceased Dec. j6th.

Dec. 31st. Menses teased Dec 26th.

Jan. 4th. II days after menses.

Jan. 77th. Menses just v.eas'^A.

SPIIYGMOGRAPHIC TRACES. 155

was taken while the patient was still under the influence of
strong excitement from annoyance. There was probably
spasmodic contraction of arteries from vaso motor irritation.
On January 3, still nearer to menstruation, the primary pulse
wave is still more developed, indeed out of proportion to the
resistance, so that the summit is peaked, especially in the trace
under pressure 6 ; dicrotism is more marked. In a condition
like this, when menstruation really arrived as expected, the
patient habitually began to suffer from ovarian pain. On
January 4 the pulse is again changed, under the influence of
a profuse sweating from a dose of Jaborandi, given with the
express purpose of lessening the intra-arterial pressure. It
is evident from the trace that the effect was obtained. It
was impossible to obtain a trace on the first day of men-
struation. The trace on January 26 represents the condition •
just after the cessation of the flow. The emptied condition
of the artery is shown by the sinking of the curve, as well as
by the smallness of the primary pulse waves. On February
21, which corresponds to January 4, inasmuch as the men-
struation was expected, yet did not arrive until ten days
later, the characters of the trace very much resemble those
on that day. The tension is raised, the fullness somewhat
increased, very markedly so over the post-menstrual trace of
January 26.

No. V is taken from a very healthy young womSn, but
rather pale, and who rarely menstruates more than once in
three or four months. She did, however, menstruate on
December 21, and again on January 23, which she considered
exceptional. January 4 and January 11, give the average
intermenstrual traces. The only premenstrual trace is on
January 13, and this is as much as ten days before the flow.
It is evident from comparison of lines 6 and 7, that the pleni-
tude of the artery is increased more than the tension ; the
summit being peaked, and dicrotism more marked. There
arc, however, elasticity elevations on the line of descent.

' rf*f f<IK WOMEN.

I'l Clutfollowil

,'irl iiftwcntj^a

Jan, 17th. 2 days altei

SPHYGMOGRAPHIC TRACES. I57

and vigorous tracing under pressure seven. The curves en
masse sink. Two days after menses the artery is full again.
Its tracing showing a combination of plenitude and tonicity,
is in marked contrast with that of January 1 1, when plenitude
existed without the tonicity.

No. VII is from a young German servant eighteen years
old, in good health, but rather pallid. December 19, repre-
sents the intermenstrual trace, which shows considerable
plenitude of the arteries, and well marked tonus.* On the
twenty-fourth, nine days before menstruation, these char-
acters are increased, and the pulse is considerably accelerated
(the number of pulse beats has been omitted). On the sec-
ond of menstruation (January 5,) the height of the primary
pulse wave is lowered, and a little dicrotism appears. But
upon abrupt cessation of the flow on the second day under
the influence of violent moral emotion, the plenitude and
arterial tension are both raised to the highest point in the
series, at this time the girl suffered from a throbbing headache.

No. VIII is from a person who represents the most typi-
cal health of any on the list, a young married woman, six
months after cessation of lactation, menstruation perfectly
regular and painless. This person possessed fine muscular
tone, and is recorded elsewhere on our tables, as capable of
walking twenty miles. The intermenstrual trace is repre-
sented at the bottom of the sheet. Four days before men-
struation, the level of the curve rises, the summit of the
angle becomes much more rounded. On the first day of
menstruation, all these characters change, the curve rises less
or sinks, the primary pulse wave is a little developed. But
though the fullness of the artery is much diminished the
tension is not, as shown by the elasticity elevations. Ten
days after menstruation the pressure and tensions have begun
to rise again, and continue to do so until reaching a maxi-

* I have never examined this subject's heart, and from the trace, suspect a
little hypertrophy.

158 THE QUESTION OF REST FOR WOMEN.

mum (on our tabic) four days before the period. It is very
possible that the real maximum was reached seven days before.
From these experiments, at all events until they should
be contradicted by others, we are justified in affirming:

1. That, taking the middle of the intermenstrual period
for point of comparison,* there is an increase in the tension
of the arteries, dependent on an increase in their plenitude
during the seven to nine days preceding menstruation. Nos.
I, II, III, IV, VII, VIII.

2. In one of the two cases where this does not appear
clearly demonstrated by our tables (No. V), the menstrua-
tion was of an unusual type ; and we lack, moreover, tables
of premenstrual days nearer than the tenth. This, however,
shows an increase of fullness, though not of tension, over the
intermenstrual trace. In the other case (No. VI), we are
again deficient in the premenstrual trace for any day but the
second.

3. The increase of plenitude and tension may be more
marked seven or eight days before menstruation than on the
first or second day before (Nos. I, II), or the increase may
continue up to the very day of the flow (Nos. Ill, VIII). In
this case the first day of the flow may exhibit little or no
lowering of the pressure or tension (No. Ill), or even show
increased pressure (Nos. V and VI).

4. As a rule, however, the pressure and tension in the
artery are both markedly lowered a few hours after the
beginning of the hemorrhage (No. I, II, V, VII, VIII), and
continue to diminish as long as this lasts (No. V).

5. The lowest point is reached immediately after the
cessation of the flow (January 26 of No. I, No. IV), and this
degree may continue for several days (Nos. Ill, V, VIII). In
some discs, however, the plenitude and tension become in

^ "Over the degree of pressure, the strength of the cardiac systole, etc., sphyg-
mograj)hic ()l)servations have only a relative value." — Cyon. Methodic, der Phy-
.siol. Experiments, 1876, p. 165.

r •«*!> af*K »"»!«

n^M. t^'u .§*y» •

RHYTHM OF ARTERIAL TENSION. 159

two davs much increased over their condition on the fourth
day of menstruation, or even on the first day after (Nos. II,
VI, December 30 of No. I).

6. VVc should conclude, therefore, that in women exists a
rhythmic wave of plenitude and tension of the arterial sys-
tem, at all events perceptible in the radical arter>% which
begins at a minimum point, from one to four days after the
cessation of menstruation, and gradu»illy rises to a maximum,
either seven or eight days before menstruation, or at any day
nearer than this, or even during the first day of the flow.

That the resistance of the wall and fullness of the arteries
should be proportionate to each other, and is so in normal
cases ; but this parallelism is frequently interrupted. (See
especially No. IV.)

How is this rhythmic wave to be explained ?

The increased pressure must depend on one of three
things: increased energy of the cardiac systole; obstacle to
the free egress of blood from the arteries ; or finally, increase
in the mass of the circulating fluid.

Now the force of the cardiac systole is certainly increased
whenever the line of ascent in the sphygmographic trace is
heightened, as it is in all our cases. When this heightening
was excessive, we found in one case that the heart beat more
frequently (No. I, December 30) — 100 a minute. But in
No. VII the frequency of the pulse was increased without
producing this remarkably high vertical line of ascent.

If, however, the energetic cardiac systole existed alone,
the line of ascent would be followed by a peaked summit
and abrupt line of descent, as in the first menstrual trace of
No. I, December 30. Again, any hindrance suddenly offered
to the egress of blood from the arteries should produce such
a trace as we have in No. VII, January 7, when menstrua-
tion was prematurely checked. But it is evident from this
trace that the resistance is increased more than the internal
pressure; whereas in our premenstrual traces, the pressure

l6o THE QUESTION OF REST FOR WOMEN.

is always increased more than the resistance. We are then
obliged to refer to the third condition of increased tension,
namely, an increase in the mass of the circulating fluid. In
perfectly normal cases the tonicity of the arterial wall is
increased pari passu with the increase of pressure. It is pre-
cisely where this is not the case that the rise of tension is
accompanied by symptoms of general nervous disturbance,
plainly to be referred to the pressure sustained by the vessels
in the nerve centres and not adequately resisted.

How may we explain the fact, (noticed under third) that
the arterial tension is sometimes higher six or seven days
before menstruation than it is on the day or two immediately
preceding ? .

If we refer to the descriptions of the uterus on the day
just before menstruation, given pp. 93 and 95, we shall see
that it is just at this time that blood begins to flew towards
the pelvic vessels, and the uter-ovarian plexus, and a slight
diversion is therefore effected from the mass of blood circu-
lating in the upper half of the body, which should be ex-
pected to somewhat lower the tension in the radial artery.
In the first month of pregnancy the same effect would prob-
ably be produced in the sphygmographic trace of this artery
from a similar cause. For during this month, the woman
often suffers from cerebral anaemia, as indicated by giddiness
upon assuming an erect position, giddiness quite relieved by
lying down, and the amount of urine, (not merely the fre-

•

qucncy of its evacuation) is greatly increased. We have not
yet positively proved that this diuresis is unaccompanied by
an increase in the excretion of urea, such as exists in the
latter months of pregnancy, but from the limpid appearance
of the urine we believe (subject to correction,) that it is inde-
pendent of any such increased movement of nutrition as
would be then implied, and due simply to an increased circu-
lation in the abdominal and pelvic blood vessels.

In the later months of pregnancy, at the same time that

. MENSTRUATION AND PREGNANCV. l6l

the excretion of urea is increased, a high tension has been
observed in the sphygmographic trace.* This has been ex-
plained by the increased mass of blood, the hypertrophied
heart, the additional pressure on the kidneys from extra
excretion of effete matter, finally by a functional increase of
nerve force. Our observations if confirmed by others more
numerous, should show that in all these respects the inter^
menstrual, and especially the premenstrual period ^ represents a
pregnancy in mijiiaturei*

In the investigation of these waves of nutrition, the great-
est assistance should be afforded by the measurement of the
blood corpuscles, according to the new method introduced
by Potainand Malassez.* We should expect to find a gradual
increase in the number of blood corpuscles from the mini-
mum point, immediately after the menstrual hemorrhage, to
a maximum just before. It is only by such a complete series
of measurements that any valuable result can be obtained.
To ascertain, as we believe has been,^ that the blood corpus-
cles are decreased immediately after menstruation, is per-
fectly useless until it has been shown whether any provision
has been made for this physiological diminution, by a cor-
responding increase immediately before.

Circumstances beyond our control, have hitherto pre-
vented us from pursuing this research, which we propose to
do later. Setting this aside, we may sum up the results de-

* Fancourt Obstet. Trans, vol. xvi. p. 263.

'Several writers admit an increased tension in blood vessels just before men-
struation, as a consequence of ** ovarian irritation." This could only act by vaso-
motor spasm, and hence hindrance to the egress of blood. But the subjective
phenomena which accompany an " irritative rise of tension," are entirely differ-
ent from those exhibited with these rhythmic traces.

'Archives de Physiologic, 1873. See the application of this method, Wil-
bouchewitch, in Archives de Physiol. iS73,and by Keys Am. Journ. Med. Science,
Jan. 1876.

•* We have not by us at this moment the memoir of Malassez, but we tliink he
mentions this experiment among his others, Archives de Physiologic, 1874^
II

1 62 THE QUESTION OF REST FOR WOMEN.

rived from the foregoing observations on the excretion of
urea, on the pulse and temperature, and finally on the sphyg-
mographic trace of menstruating women during the different
periods of the month. We find that in the majority of cases,
the excretion of urea is increased during the few days pre-
ceding menstruation, over that of the intermenstrual period;
that it decreases during the menstrual flow, and is at its min-
imum just afterwards ; that the pulse shows no uniform rate
of variation, but that the temperature rises just before men-
struation, to fall during the flow, but at this tinie rarely
reaching the point of the intermenstrual period. Finally that
the sphygmographic trace shows a constantly increasing rise
of arterial tension from a minimum point reached just after
menstruation to a maximum point just before, but rapidly
lessened during the menstrual flow.

From our tables as well as from the experiments made by
many others,' it is certain that increased nervous action de-
termines an increase in the excretion, and probably in the
production of urea. It is important for our purpose, how-
ever, to remember that an increase in the number of the blood
corpuscles has the same effect. Thus men in whose blood is
a larger number of blood corpuscles, habitually excrete a
larger amount of urea than women.

Whatever the ultimate cause, however, it is unquestionable
that this phenomenon always implies an increased movement
of disassimilation and oxidation of albuminous tissues,
principally of the nervous and muscular. This may exist
alone, as in diabetes or in fever, but when accompanied by
good health and increased vigor, certainly presupposes a pre-
vious increase in the rate of assimilation, that is of nutrition.

Now in the majority of women, the week preceding men-
struation is a period of increased vigor, consciousness of in-
creased nervo-muscular strength." We are therefore justified

* Neubaucr and Vo^cl, Analyse dcs Ilarncs.

• The cases where the contrary is observed will be considered later.

VARIATIONS OF UREA. 1 63

in assuming that the increased excretion of urea observed in
the majority of cases at the premenstrual period, implies an
increased movement of nutrition, although not very marked.

When the urea continues to increase during the men-
strual period, it is probably due to other causes, perhaps to
the nervous irritation which in many cases accompanies
menstruation.

The diminution of urea during the flow, is susceptible of
three interpretations ; either the general nutritive movement
of assimilation and disassimilation has decreased, or the urea
in the blood has been carried off by the menstrual hemor-
rhage ;* or finally the assimilation of albuminous substances
from the blood is diminished, so that these pass off in the
shape of the albuminoid constituents of the menstrual blood.
The first is the opinion of Rabuteau, who, as we have seen,
explains the decrease by the loss of the red corpuscles needed
for the oxidation. As only five or six ounces of blood arc
lost during menstruation, and the proportion of urea in the
normal blood is almost imperceptible, (one gramme in the
entire body) it is improbable that the amount of urea defi-
cient could be excreted as such in the menstrual blood, whose
composition is the same as that circulating in the veins. We
accept therefore, the first or third explanations, probably
both.' The slackening of the movement of nutrition in
nerves and muscles, is in strict correlation with the loss of
oxidizing jrorpuscles by the hemorrhage. Finally the diminu-

' In the ultimate stages of renal cirrhosis, when the excretion of urea by the
kidneys has become almost impossible, intestinal hemorrhage not unfrequently
occurs, and compensates the suppression of the normal evacuation. We have
recently seen such a case in our own practice, and where an expensive ulceration
developed around the anus which we ascribed to irritation of ammonia derived
from the urea presumably c^mtained in the blood. At the autopfiv, no visceral
disease was found, except the most extensive cirrhosis of the kidneys, anrl super-
ficial ulceration of the large intestine.

• The relative>analysls of blood for albumine would be as desirable as for blood
corpuscles, but much more difficult to obtain.

164 THE QUESTION OF REST FOR WOMEN.

tion of urea during the days following menstruation, at first
sight appears to be analogous to that observed after patho-
logical hemorrhage. In the latter case, however, the patient
always suffers from a feeling of exhaustion, just as indeed, do
certain persons after menstruation, whether this be excessive
or apparently normal in quantity. But usually, as BischofT
long ago insisted, women feel very well at this time, fact en-
tirely incompatible with the supposition that nervo-muscu-
lar nutrition has been depressed below its normal level. We
must rather infer that the depression is relative, and shows
a decrease from a temporary elevation. . .

The rise in temperature indicates the same curve of oxi-
dations as the alterations in the amount of urea, and again,
we are led to suspect as a probable proximate cause, an in-
crease in the number of blood corpuscles.

Finally the rise of the tension as indicated by the sphyg-
mographic trace, seems to intimate, for the reasons above
given, an increase in the mass of the circulating fluid.

In all the details examined therefore, we find evidences
of such a gradual but steady preparation for the menstrual
hemorrhage, as should exclude the idea that this, when nor-
mal, has any tendency to deplete the nutrition or lower the
strength. It is to be regarded as the simple equivalent of
an accumulation effected by a constantly rising wave of
nutrition, primarily, (in all probability) affecting the blood,
but secondarily, and as a result incidental to the n\ain object
of the wave, affecting the nervous and muscular system
through which that blood circulates. The blood of the
woman, non-pregnant as well as pregnant, maintains constant
provision for the nutrition of offspring, just as the sap of the
tree contains constant provision for the nutrition of buds.

The special variations of this blood, /". e, as regards sex,
are all relative to this circumstance, but incidentally, the
nutrition of the woman's own organs is effected.

If richer blood circulates in a slightly increased quantity,

RHYTHMIC REPRODUCTION. 165

and under a higher pressure, through the nervo-muscular
organs, the nutritive movements in their tissue^ are acceler-
ated, and the acceleration is marked by the increase of urea.
When, in virtue of the rhythmic movement inherent in their
form of nutrition, a portion of the nutritive fluids of women
becomes in excess of their individual needs, this excess be-
gins to accumulate in the circulation, until finally, the tension
becoming excessive, the closed system gives way at its weak-
est point, the blood vessels of the fattily degenerated uterine
decidua, and hemorrhage occurs.*

From all this it should follow that reproduction in the
human female is not intermittent ^ but incessant^ not periodical^
but rhythmic, not dependent on the volitions of animal lifCy but
as involuntary and inevitable as are all the phenomena of
nutritive life, Vulpian, (Physiol, de Tamnios et de Tallantois.
J. Br. Sequard, V. i. p. 616,) remarks that the allantois of the
chicken shows rhythmic contractions from the eighth day,
and the amnios from the sixth or seventh, at a time when
no nerve elements exist in the amnios, so that its rhythmic
action cannot be dependent on periodical nervous influence.
•The author questions whether the movement can be attrib-
uted to alternate modes in the nutrition of the blood. He is
prepared to admit that the rhythmic type is general to the
movement of nutrition.

■

In animals, many nutritive phenomena, essentially the
same as those of plants, appear to change their character,

' Leigois ridicules the " plethoric " theory of menstruation on ihe ground that
woman's blood has been shown to be habitually anemic relative to man's, i. e. to
have fewer blood corpuscles than men's. From what precedes it is evident that
no measure of blood corpuscles is of value, unless repeated thioughout the month.
Moreover, even were an absolute inferiority proved, we should attribute it to the
absolute inferiority of muscle needing less oxidation. '* There is," observes
Paget, loc. cit. p. 1 1, " no fixed standard to the composition of the blood. From
birth onwards the blood and tissues of each creature are adapted to one another,
and the maintenance of health depends on the maintenance of their mutual
reactions."

l66 THE QUESTION OF REST FOR WOMEN.

because in their complete evolution the functions of animal
life, especially voluntary movement, have intervened. Thus
in the two great departments of nutrition, the primary and
the ultimate, absorption of food, and reproduction of the
individual, the movements that in plants depend upon ex-
ternal agencies, in animals depend on the individual volition.
Currents of air being food to the plant, currents of water
being food to the mollusk, w^hich in its immobility resembles
an important character of plants ; but the animal must go in
search of its fodder or prey.*

These remarks are not irrelevant, because of the wide-
spread though unconscious perversion of view that has re-
sulted from the habit of associating menstruation with the
sexual instead of the reproductive functions of women ; and
of expecting it to be accompanied by some especial excite-
ment of the cerebro-spinal nervous system, such as must
necessarily hold in abeyance all other activity of the central
nervous organs.

The suggestion so frequently made (see former quota-
tions), that by means of menstruation celibate women were
enabled, to a certain extent, to compensate their celibacy,
rests upon the slenderest foundations. But we should assert

* Nevertheless the voluntary movements of the animal are ultimately depend-
ent upon rhythmic waves of excitation in the masses of nerve matter where they
originate. Food is brought to the ganglion cells by the blood currents, a« pas-
sively as to the oyster by the water currents. " Let us remember," observes
Wundt, *• that slight excitations generally vanish in the central substance of the
cell, while stronger excitations set free its latent force. The excitation of the
blood current impinging on the periphery of the cell must accumulate until they
reach a given strength, sufficient to liberate the force of the cell, which is then
transmitted to its central region, and thence to its motor nerve. After this dis-
charge of force, equilibrium is restored, and the process begins all over again.
Nerve centres submitted exclusively to the excitation of the blood act automati-
cally and rhythmically. . . . This rhythm is interrupted or rendered irregulai
when the influence of other ner\'e centres inhibits the discharge of accumulated
force." (Untersuch. zur Mechanik der Nerven. 1876.)

CONTINUITY OF REPRODUCTION. 1 6/

that the menstrual process, peculiar' to the one class of
animals who are capable of avoiding or of missing an oppor-
tunity to propagate their species, indicates that this freedom
of choice is only superficial or apparent, and that the initial
steps of reproduction are being constantly, not periodically,
taken by the force of nature, working independent of human
will or of social accident. The woman buds as surely and as
incessantly as the plant, continually generating not only the
reproductive cell, but the nutritive material without which
this would be useless, whether or no either be utilized in
further development. Whence is this nutritive material
obtained ?

* Notwithstanding Pouchet. It would bring us too far from our subject to
discuss the vexed questions of this peculiarity. It is difficult to understand that
a provision for the nutrition of an embrj-o in one mammalian animal should not
be required in all. Pouchet's opinion, that in many animals the same projwr-
tionate amount of blood is diverted to the pelvic organs during the rut, but that
those being looser in texture are able to retain it without evacuation, seems ex-
tremely probable. Moreover, if in animals every rutting season is intended to
be followed by a conception, the habit of evacuation of the provisional nutriment
would never be established.

SECTION V.

THEORY OF SUPPLEMENTAL NUTRITION.

THIS certainly does not come from extra nourishment,
for women eat less than men, and female animals and
female plants eat no more. It must therefore be derived
from a reserve drawn from the ordinary nutritive supply of
the body, and it is the possibility of making this reserve
which constitutes the essential peculiarity of the female sex.*
Spencer's generalization, already made by Haller, that
reproduction is only possible when growth ceases, affords no
explanation of the differences between the sexes which physi-
cally are so much more marked in human beings than in the
lower animals. His further proposition, that in w^omen indi-
vidual development must be arrested on a lower type than
that of men, in order to leave a margin for reproduction, is
useless, and even untrue, on account of the width of the
generalization. Nevertheless, in view of the primitive equal-
ity or even identity of the sexes," this margin must exist, the
reserve must be drawn from somewhere in the sex which
sustains the greatest cost of reproduction ; and as the most
obvious difference between the sexes consists in the amount
of motor force possessed by each, and in the development of
the motor apparatus, the muscles and the bones, the nutri-

' Even if it were admitted with Hermann, that the ordinary cost of reproduc-
tion is the same in both sexes (sec pp. 12 and 173), this would no longer hold
during gestation. For this, an organic habit of nutrition must be provided, quite
peculiar to the female.

* Embr}'ologically and to a less extent during childhood.

LOCOMOTOR APPARATUS OF WOMEN. 169

tive margin theoretically admitted, has often been derived
from this apparatus.

This entire locomotor apparatus is much more developed
in men than in women. The muscles are more massive even
relatively to the size of the body, and the body in all male
animals above fishes is larger. " If it be asked why girls
arrive at puberty earlier than boys, we reply that as men are
much larger and stronger than women, as they have the body
more solid, more massive, the bones harder, the muscles more
firm, we should expect that the time needed for the growth
of their body would be larger than that necessary for women ;
and as it can only be after the completion of growth, that the
surplus of organic nourishment begins to be sent from all the
parts of the body to the organs of generation, it happens that
in women the nourishment is sent there sooner, because their
growth is sooner completed.* The development of the bones
is the consequence, not the cause of the development of the
muscles, formed earlier, and of superior physiological signifi-
cance; size is added to motor force, not motor force to size.
Comparison between the nervous apparatus of the two sexes,
though often made, is by no means so easy. We may, how-
ever, consider the following facts to be proved, i. That the
structural development and functional activity of the central
nervous organs, is by no means in proportion, inverse or
direct to their mass.

2. That this mass, especially as considered in the white
substance, is proportioned to the degree of muscular de-
velopment.

3. That the bony cases containing the central nervous
organs, although in their growth closely following that of
their contents, are nevertheless, in their outer aspect in the
development of their prcyninences, rugosities, apophyses,
closely related to the development of the muscular system.

* Buffon, Hist. Naturelle de rhomme. Quoted by Quetelet, Anthropometric,
p. 201.

170 THE QUESTION OF REST FOR WOMEN.

These characters even appear on fossil skulls,* whose sex is
(presumably) easy to distinguish by them.

4. To these propositions, generally admitted, may be per-
haps added a fourth based upon less certain data. The local-
ization in the anterior lobes of the cerebral hemispheres, of
ideo motor centres,' tends to attribute if proved,* the prepond-
erance of this portion of the brain in men, as compared
with women, at least in part to the preponderance in them
of muscular strength and motor force.* Whether or no the
ideo motor centres of the convolutions be admitted, it is indis-
putable that the largest and most exclusively motor tract of
nerve fibres, that which is carried up in the foot of the
peduncles, terminates entirely in the anterior province of the
brain, namely in the cortex of the cerebral hemispheres, in
the corpora striata, and in the extra ventricular nucleus.
(Huguenin, Wundt.)

From all these circumstances we may at least presume,
that any general inferiority in the entire mass of the central
nervous organs in women, as compared with those of men,
(out of proportion to the smaller size of the body of course)
principally relates to the organs of motility, the anatomical
conditions of sensibility and of thought remaining the same.
This fact leaves much room for variation in the dynamical
conditions. Further, that while the mass of these central
organs of motility is permanently less, we have no facts
which prove an equally necessary inferiority in the elabora-
tion of their structure.

This distinction is extremely important, for if, owing to
the smaller mass of muscle, the woman requires less quantum

* Qiiatrcfages ct de Hamy, Crania Ethnica, 1873.

' Ilit/ig, Untcrsuch ucberdas Gehirn,i874. Wundt, Physiologischen Psychol-
ogic. Dalton, Report of Committee of N. Y. Society of Neurology, 1875. Ferrier,
P'unclions of the Brain, 1876.

* It is vigorously disputed by Dupuy, These de Paris, 1873, and denied by
Hermann.

* The exact relative ]>roportions between different parts of the brain in the
two sex«fs, is by no means completely determined.

RELATION BETWEEN MUSCLES AND REPRODUCTION. I/I

of nerve force to be generated in the motor centres, yet the
tonus of each individual fibre is as important for her as for
the man, and hence there is as much demand for the power
to generate force in each nerve cell ; in other words, for as
fine a structure of the nerve centres.

That this power is frequently deficient in women, that to
it is due the major part of both their inefficiencies and ail-
ments, is unquestionable, but there is nothing to show that
such deficiency is either a primary or secondary sexual
characteristic.

Of all the tissues, therefore, it is the muscular, to which
the bones and probably certain portions of the nervous sys-
tem are accessory or correlative, that exhibits the greatest
difference in the quantum of development in the two sexes.
These differences are most marked in the human race, and
increasingly so in proportion to the luxury of civilization ;
but they exist, at least the preponderance of size exists, in
the larger number of the vertebrated animals above fishes.

Again, these differences are not sensibly perceptible until
the approach of puberty, children under ten years of age
being, if submitted to the same regime of exercise, about
equal in muscular force and development. We arc, there-
fore, almost forced to the conclusion that ** the arrest of indi-
vidual development " which marks the unfolding of repro-
ductive powers in the girl, does not take place in her entire
body,* but in her locomotor system, including all the organs
comprised in it, muscles, bones, and nerves, or motor nerve
centres. This arrest implies that at this epoch the muscles
begin to refuse to assimilate a certain proportion out of each
group of nutritive molecules which is brought to them by
the circulation. They cannot refuse all, for then their waste
would not be repaired, and they would atrophy. Nor can it
be said that the amount of nutriment brought to the muscles

* The question of arrest of mental development is foreign to our subject,
except as implied in the question of development of nerve centres.

1/2 THE QUESTION OF REST FOR WOMEN.

merely remains the same as it had been during childhood.
If the amount and distribution of nutrition did remain the
same, the body must necessarily remain in the same condi-
tion, permanently childish, incapable of reproduction. This
presumption is realized in certain idiots and cretins. Now
the amount of food taken by boys at puberty does increase,
and they continue to grow, while girls, even in full health,
hardly eat any more at sixteen than at ten, and their growth
usually ceases. The amount of nutriment, therefore, is pro-
portioned to the growth of the individual, and approximately,
to the bulk of the muscular osseous system.* The only
change possible in order to secure a margin of nutrition for
reproduction, must be in the distribution of nutriment.
Since this margin is required in both sexes, the change in
distribution is required in both, and is effected throughout
the entire animal as well as vegetable creation, by means of
an arrest of individual growth. The difference in this respect
between the two sexes, is a difference not of kind, but of
degree. It is a difference not explained, as has been foolishly
asserted, by the presence in the female of more highly devel-
oped organs of generation, since they are exactly balanced
in the two sexes.* An excess of bulk in one direction is
compensated by an inferiority in another, so that the sum
total is the same. Hence here is no reason for arresting
muscular development in the woman earlier than in the man.
Again, any extra nutrition demanded by the increase of size
in the uterus and ovaries at puberty, is much too trifling to
necessitate any important change in the nutrition of other
organs. It could not be a cause of change in the distribution
of nutrition, because nutritive currents have been from birth
directed to the same organs, and, for several years before

* Of course mere size, depending on fat, is excluded from consideration.

• The details of these analogies are so familiar to anatomists that it would be
useless to refer to them, were it not for the extraordinary statements that have
been made concerning the preponderance of such organs in woman. See Flour-
ens, Cours d' Embryologie.

PHYSIOLOGICAL CHANGES AT PUBERTY. 1/3

puberty, in almost as great abundance as after its estab-
lishment.

The demand for an altered distribution of nutrition is not
in relation to new organs, but to a new function, or it
refers not to special anatomical tissues, but to physiological
processes in which all tissues share. The difference in the
degree of the demand, or the cost of reproduction in the two
sexes, is partly indicated by the different degrees in which
the individual nutrition is altered. The difference for the
cost of the processes actually instituted is not so great. In
the woman the extra development of the germ cell is com-
paratively trifling, the amount of nutritive fluid (as repre-
sented by the menstrual blood) more abundant. In the other
sex, the analogous nutritive fluid is much less in quantity, but
on the other hand, the germ cells begin to be formed at
puberty, and if smaller in size, are more numerous than the
ova. In the woman it is the potential cost of reproduction
which is in such immense excess. Ovulation and menstruation

do not represent, as do the corresponding processes in the
man, the entire contribution of the organism to reproduction ;
they only sketch out the work that is to be accomplished- by
it in pregnancy. It is for this especially that a new habit of
nutrition of the entire body is required, and it is instituted
in advance, just as the habit of breathing with the upper part
of the thorax is begun, a habit useless except in pregnancy.
Were it merely necessary to provide an amount of nutriment
corresponding to what is contained in the ovule, and the five
or six ounces of blood lost in the monthly hemorrhage, or
were menstruation constant, /. c, a physiological phenomenon
of short intermittence like digestion, it is conceivable that
this should have been done in the one sex as in the other,
by means of an extra amount of food, and by the arrest of
growth after that had reached a higher degree of develop-
ment. Instead of this, the cost of reproduction in its initial
stage, is provided for by the same mechanism which will be-

174 THE QUESTION OF REST FOR WOMEN.

come necessary in a later stage. The amount of nutriment
is not increased, but a portion of it is diverted into new chan-
nels. The organs from which it is so diverted, can be no
other than those which cease to develop in bulk and func-
tional power, not only absolutely but relatively to the rest of
the body, and fall below the typical possibility of the race as
exhibited in men. The only organs in which such changes
are evident are the muscles, and their accessories the bones.

If the first establishment of menstruation is correlative to
a diminution of muscular nutrition, we are already justified
in looking in this same direction for the provision that we
should expect to be made for its continuance. It is almost
an axiom in physiology, that the entire interval between the
recurrences of a rhythmically intermittent process, is occu-
pied by preparation for that process. The longer the interval,
therefore, the more salient must become the marks of pre-
paration. In the case in question, the interval is long enough
to reproduce in miniature at each menstrual period certain
conditions of the first menstruation. To carry out the re-
semblance, we should be able to detect a gradual deviation
from muscular nutrition resulting in an accumulation in the
blood vessels of nutritive fluid refused by the muscles, until
the tension has been raised to a maximum just before degen-
eration of the uterine mucous membrane permits the blood
vessels to rupture at this point. There can be no question
that this series of phenomena occurs at puberty. In what
way could it be repeated at succeeding menstruations ?

Two distinct series of chemical processes are carried on
in muscles, which, as both concern molecular movements of
integration and disintegration, may be classed together under
the general head of nutritive. Only one, however, really
relates to the nutrition, i, e, to the development or the repair
of waste, of the muscular fibre proper. This is the series of
processes by which is effected the assimilation of plastic
(albuminous) material. The other series of processes is con-

MUSCULAR FUNCTIONS. 1 75

nected with the function of the muscle, and though, by affect-
ing the mass of juices contained in the muscle, it modifies
the size or nutrition of the organ as a whole, it is not directly
connected wifh the assimilation in the fibres constituting the
parenchyma. It has been demonstrated that the contraction
of muscles during exertion is attended by an increased ex-
cretion of carbonic acid, while the excretion of urea remains
the same. This is positive proof, and is accepted as such by
all physiologists, that the heat required for the production
of motor force is not derived from combustion of the albu-
minous parenchyma of the muscle, but of the substances,
principally hydrocarbonaceous, contained in its juices.
Schiff compares these to the coal contained in the locomo-
tive, whose motor power is derived from oxidation of its con-
tents, and not of the substance of its machinery.

The chain of phenomena which intervene between the
oxidations in the muscular juices and the contraction of the
muscular fibre, is somewhat variously interpreted. Accord-
ing to some physiologists, the lactic, and possibly other acids,
formed, partially coagulate the myosine of the fibre, which is
thus condensed. Tetanic contractions, and the rigor mortis,
are only an exaggeration of the condition present in every
living movement (Hermann, Brown-Sequard). According to
others, the sarcous elements move spontaneously like the
amoeba under the stimulus of the heat, protruding in one
direction while retracting in another, or the heat may be said
to be directly converted into molecular movements within
these sarcous elements (Pettigrew '). However immediately
effected, contraction of muscular fibre quickens the circula-
tion by compression of the blood vessels, and the accelerated
blood current removes the products of oxidation accumu-
lated in the muscle, and brings a fresh supply of oxidizable
material, together with the plastic material for the repair of
waste in the fibre. Thus the conditions of function and the

' This writer has explained but I believe not originated this theory.

176 THE QUESTION OF REST FOR WOMEN.

conditions of nutrition of this fibre are fulfilled at the same
time, provided the composition of the blood be normal.
Hence the peculiarly intimate relation known to exist in
muscles between the activity of their functions and the per-
fection of their nutrition.

Four circumstances may determine an alteration in the
chemico-vital processes sustained in muscles. First, the com-
position of the blood may be altered. Deficiency of blood
corpuscles, or anemia, interferes with the oxidation of the
juices, hence with the entire series of processes necessar>' for
muscular contraction ; hence by imperfect contractions the
circulation becomes sluggish, oxidized material is not re-
moved, but, accumulating, causes the sensation of fatigue,
w^hich has been proved experimentally to depend upon such
accumulations. The same sluggishness of circulation inter-
feres with the supply of plastic material so that the nutrition
of fibre suffers coincidently with its function. The clinical
expression of these phenomena is of ver>' frequent occurrence.
Other variations in the composition of the blood would pro-
duce analogous results.

2. Diversion of the blood supply by causes external to the
muscle has the same double effect. The function is inter-
fered with first, so that in the regular physiological deriva-
tions of blood from the muscles to the gastro-intcstinal tract,
which correspond to the intervals of digestion, (see p. 106)
the activity of function is alone affected. Before nutrition
could be impaired, (we are speaking of normal conditions,)
the blood wave returns.

3. The oxidations of hydrocarbons in muscular juices, are
not only utilized in the production of motor force, but are
the principal source of animal heat. Further, Liebermeister
has shown that in all probability, the regulation of the heat
of the body to a fixed standard, is effected in the superficial
layer of muscles just underlying the skin. To the standard
of temperature existing here, the temperature of the body is

MUSCULAR FUNCTIONS. 177

conformed in spite of external variations, by means of im-
pressions made upon the superficial muscular or subcutaneous
nerves.* The chemical processes furnishing motor force, are
therefore controlled by the same reflex innervation which
regulates temperature, and may be expected to vary like the
latter, sometimes under the same, sometimes under other
conditions.

4. The assimilative power of the muscular fibre must be
presumed to vary like that of all other anatomical elements,
though it must be far from possessing the active influence in
abstracting assimilable material, that we have reason to at-
tribute to ganglionic nerve cells. The lesions which afford
positive proof that assimilation has diminished or ceased,
the blood supply remaining the same, fatty and waxy de-
generation, and simple atrophy, have all been traced to alter-
ations in the temperature or composition of the blood, to an
arrest of innervation, or to irritation of the nerve centre with
which the muscular nerve is connected. Apart from these
circumstances, we know of no proof that the muscular fibre is
able to refuse to assimilate nutriment that may be brought to
it. Provisionally, however, we may admit such a possibility.

Finally, voluntary innervation, determining voluntary
muscular contraction, has a most powerful influence over
muscular nutrition, but as it acts merely by initiating the
chemical processes already considered, its immediate effect
must be resolved into one of them.

We may now return to our starting point, and inquire
whether there be any evidence that one or more of these pro-
cesses in muscles, are so modified, that nutritive material is
periodically accumulated in the blood to meet the demands
of reproductive nutrition.

On the most superficial view, the second condition men-
tioned above seems to be realized by the derivation of blood
to the pelvis, and therefore, presumably, from the muscles

* Lehrc des Fieber, 1876.
12

178 THE QUESTION OF REST FOR WOMEN.

during the menstrual hemorrhage. The alternation between
the circulation of the muscles, and of the generative intestine,
would be analogous to that shown to exist between the mus-
cles and the digestive tract. But the analogy would fail in
one important point. The blood diverted from the muscles
during digestion, is returned to them afterwards, enriched
by fresh nutriment, but the blood diverted during menstrua-
tion is lost. Unless, therefore, a surplus had previously been
accumulated in the muscles, the hemorrhage, if effected at
the expense of their circulation, must on each occasion tend
to lower their nutrition.

On the other hand, the gradual increase of vascular ten-
sion during the intermenstrual period, and its maximum just
before the menstrual flow, must, other things being equal,
increase the nutritive movement in muscular tissue, so long
as it lasts. This is the first indication that for a temporary
diminution of muscular nutrition during the menstrual hemor-
rhage special provision is made, by means of a special increase
in this nutrition just before the flow.

So much for the second condition modifying muscular
nutrition, and its relations to menstruation. The fourth con-
dition — diminution in assimilation of plastic material — exists
at puberty, and causes the arrest of muscular development,
characteristic of that epoch. During menstrual life, no such
great change in assimilation could be expected to take place,
nor does it, but we may mark lesser variations approximately
by measuring the excretion of urea. In a general way it
may be said, that the quantity of urea measures the quantity
of function performed by the nervous system, and the quan-
tity of nutritive disassimilation effected in the muscular.*
This proposition may be disputed by those who assume that
a ** waste of tissue '* accompanies all nervous action, and
measure that waste by the urea, whose quantity is undoubt-

* It docs not vary with the functions of the latter, which are measured by the
excretion of carbonic acid.

UREA AND NERVO-MUSCULAR FUNXTIONS. 1/9

cdly increased by such action, most demonstrably by action
of the brain. But we believe that there is no proof that the
functioning of nerve cells is necessarily accompanied by dis-
integration of their essential structural elements. We shall
return to this point further on. In the mean time, we are
justified in resting upon the well averred coincidence between
increased brain function and increased excretion of urea, with-
out going behind it to the hypothesis of structural waste.
The fact itself is already shown quite markedly on our tables.
Apart from this hypothesis, however, and during equilib-
rium of function in the nerve centres, it must be admitted
that we have reason to suppose that an increased movement
of disassimilation in nervous tissue apart from increased func-
tional activity must be followed, as in muscular tissue, by an
increased excretion of urea. The increase during fevers and
diabetes is habitually ascribed to this double source, disinte-
gration of nerve and muscular tissues. Now our tables of
urea have shown that, besides marked variations according
to degrees of mental activity, a regular curve of variation
occurred (in the majority of cases), according to which the
amount of urea excreted was increased during the few days
preceding menstruation, generally began to fall during the
flow, to reach a minimum point just afterwards. In some
cases it was increased during the flow, and in some of these
cases, at least, this increase seemed to be due to increased
mental exertion. Rut when this circumstance is eliminated,
the quantitative curve of urea indicates a certain increase of
disassimilation in nervo-muscular tissucfe during the premen-
strual period, and a diminution of the same during the men-
strual and post-menstrual period. The diminution may pre-
sumably be attributed either to diversion of the circulation
or to loss of blood corpuscles. The premenstrual increase
can only be explained by a previous increase in the move-
ment of assimilation — such as should result from increased
blood pressure in these tissues.

l80 .THE QUESTION OF REST FOR WOMEN.

There is, therefore, no evidence of a direct rhythmic
diminution in the assimilation of plastic material in muscu-
lar tissue, by which nutritive material might be periodically
saved for reproduction. There is, however, evidence of a
temporary diminution of muscular nutrition during the men-
strual flow in correlation with a relative temporary increase
which occurs just before it.

In regard to the first condition modifying muscular nutri-
tion, namely, the composition of the blood, the absence of
the positive experiments on numeration of blood corpuscles
which may now be so readily performed, compels us to defer
speculation. If we should argue from analogy with the vas-
cular tension and the urea curve, we should expect to find an
increase of blood corpuscles during the premenstrual period,
which should compensate their loss during menstruation.
But if we judge by the analogy of pregnancy, we should ex-
pect to find a diminution of blood corpuscles relative to the
plasma, just before the menstrual parturition — a diminution
which, in pregnancy, we have inferred to rather imply an in-
crease of plasma. It is noticeable that this condition of the
blood in the latter months of pregnancy coincides with a great
rise of vascular tension, and increase in the excretion of urea.
Leaving this most interesting detail to be determined by fur-
ther researches,' we may consider the third possible modifica-
tion of chemical processes in muscles, that, namely, of the oxi-
dations of hydrocarbons, upon which depends the accomplish-
ment of muscular function. We have seen that these oxida-
tions must be modified by the abundance and rapidity of the
circulation, and also by the voluntary innervation which
compels muscular contraction. But the fact that these same
processes arc slackened or quickened according to the de-
mand for the production of heat — demand appreciated by
impressions produced upon and transmitted by the super-
ficial muscular nerves — shows that modifications of these

' Which we have already begun.

THEORY OF MUSCULAR RESERVE. l8l

processes may be initiated within the muscle, as well as con-
trolled from without, by, for instance, variations of circulation.

Let us suppose that at any j^iven moment, an ideal mo-
ment of complete equilibrium, the amount of oxidizable
material in the juices of the entire muscular system consumed .
in an hour = A.

Let us further suppose that at the end of the hour a spon-
taneous slackening of the oxidations takes place under the
influence of reflex nervous impressions analogous to those
which, in some as yet unknown manner, regulate the produc-
tion of heat, at the end of the second hour, the total amount
of material consumed would = A + A — a.

If the ratio of diminution continued the same, we should
have at the end of the third hour, A-fA — a + A — a, and
so on. Let A ~ 12, and a = i. Then at the end of the second
hour we have 12 -f 12 — i = 23. At the end of the third,
12 + 12 — I H- 12 — I, or 23 -f II =34, and at the end of
twelve hours would equal 12 X 12 — 11 = 133. Had the
equilibrium been maintained, the consumption at the end of
twelve hours would equal 144.

Eleven molecules of oxidizable material would, therefore,
remain in the circulation, because while the supply of nutri-
ment to the blood remained the same, elimination from the
blood had been diminished to that amount. The change in
the mass of the blood would be greater than is indicated
merely by these figures. The afflux of blood to the muscles
is diminished by diminution in the activity of chemical pro-
cesses going on in them, out of proportion to the diminution of
eliminated material. As a consequence, the whole amount of
blood remaining the same, there must be a surplus capable of
being diverted to other organs, and which, until so diverted,
continues to circulate in the blood vessel and increase arterial
tension. Thus would be fulfilled the conditions which are in
fact observed just previous to menstruation, and in this wide
spread alteration of nutritive processes spontaneously initi-

iit.^'i :r. rr. i r»:l-f *- rr'^rfr-Z- ~ : t r : t^eir issi^^ilitioo, but their

W V -

r --.:•:'. r.. x * ^a ' -. i cisr :- ver i rji^r-r^tici— y fatia^ractorj- origin
5',r tl-.-t turpi -Tr r.utrliive zLiTerlil perl-i-dicilly wasted in

F:r_^.v. sr'nilt the 'iiversion of bl»i 'V/if the voluntars'
rr.-*.il*t. 'ilrr-ir-i-rhci their ru~c::on^ dtkicirt'. a correlative
af?!j.x of b'.'»i /.-• the -terus, 5h:-.il»i increase iSs functional
Cic*ac;tv, /- <^. the c jr.tractilftv i-f its muscular fibre. The
%iTiaII '.icrea-i'i of c jn:ract:Ie p>3wer acquired at each menstni-
atron. ii neeiied to f^rce bl'»d to'^ards the cavitv of the
uti'rrjT, a* the en vrmous increase at oarturition is needed to
exp^I the frjit from the cavity.

The oxidations of muscular fuices are measured bv the
quantity of carbonic acid formed, which is a measure both
for the pro<iuction of heat and the intensity of muscular
contraction.

It has long been admitted that, durin^j menstrual life,
women exhale less carbonic acid than men. measured per kil-
ogramme of weight of body. It is also known that in case
of amenorrhea, other than that of pregnancy i?» the pro-
portion of carbonic acid in the expiration of the one sex
becomes equal to that of the other. Xo measurements have
been made comparing the amount of carbonic acid e.xhaled
by women at different periods of the menstrual c\-cle. But
the general correlation between menstruation and a diminished
quantity of carbonic acid was insisted upon long ago by
Andral and Gavarret, whose experiments are quoted by Aran
in defense of a constitutional, as opposed to a purely local
theory of menstruation. The experiment required to test the
truth of our hypothesis, consists in a daily measurement of
the amount of carbonic acid excreted throughout an entire
menstrual cycle. According to the hypothesis, this amount
should be at a maximum at the middle of the intermenstrual
period, should then gradually diminish to a minimum just
before menstruation, and should be found immediately after

NUTRITION IN MUSCLES AND NERVES. 1 83

menstruation, about the same as just before, and this should
be the case notwithstanding a different curve for the abund-
ance of red corpuscles in the blood.

On account of the laborious difficulties of this experi-
ment, we have as yet not been able to carry it out with the
necessary precision, and defer appealing to it until researches
in regard to the other nutritive curves have been further
developed. We are, however, justified in advancing the
theory, as a strictly " verifiable hypothesis,** and therefore
admissible. Partial verifications we shall endeavor to adduce
further on, from several details of pathological phenomena.
It is worth while in this place, however, to consider whether
the arguments we have offered in favor of an alteration of
muscular function as a proximate cause of menstruation, i,c\^
of reproductive capacity, in any way apply to the function
or nutrition of nerve centres. There is much looseness of
thought in the present day about these latter functions, and
confusion between them and those of the muscles ; and in no
connection, perhaps, is this confusion more palpable, than
when the reproductive functions of women are under con-
sideration.

Obscure as is our knowledge of the chemical processes
of nutrition in either muscles or nerves, a few facts are well
established. Assuming, for the moment, that the assimila-
tive processes securing the repair of waste are essentially the
same in the nerve cell and the muscular fibre, we have every
reason to believe that there is a striking contrast between
•the chemical processes underlying their respective functions.
It is certain that in muscle these processes consist of a series
of oxidations, or of reduction of complex elements to simpler.
But, as Wundt points out, the formation in the nerve centres
of the complex molecules of lecithine, from the less complex
molecules of fat and albumen, proves that in at least these
tissues of the animal body are carried on chemical processes
quite other than those of oxidation. Instead of a reduction

l84 THE QUESTION OF REST FOR WOMEN.

of complex molecules to simpler, long held to be the chemi-
cal process peculiar to animal nutrition, there is a synthesis
of simpler elements to more complex, such as takes place in
plants/ Now, according to the law of correlation of forces,
force becomes latent during chemical combination, and is set
free during chemical decomposition. During the formation
of lecithine. therefore, in the interior of a ganglion cell
force becomes latent, or is stored up in the cell. This pro-
cess constitutes the " negative or internal work ** of the cell.
When the molecule of lecithine is decomposed, force is lib-
erated, and in quantity proportioned to the extreme atomic
complexity of the molecule. This force, discharged along
the motor fibre emanating from the cell, constitutes the
** positive or external work '* of the latter. It is not a
strained hypothesis to admit, with Wundt, that the negative
work is principally effected in the interior of the cell, and
the positive at the periphery. In a state of repose or equi-
librium, a rhythmic alternation is constantly maintained
between the two processes — rhythm which may be modified
by any circumstance, physiological or morbid, which facili-
tates or impedes the peripheric discharge of force, or which
increases or diminishes its central accumulation so that the
proportions between the two processes are changed. This
mechanism for the generation or accumulation of force is
probably limited to the ganglionic nerve cells, and in inti-
mate connection with their recognized influence upon gen-
eral nutrition. An absolutely larger amount of material
must be consumed in those chemical processes which result
in the generation of nerve force, than in those which repair
waste in tissue. The assimilation of albuminous nutriment
to repair waste in the muscular mass, is, on the contrary,
from its greater size, on a larger scale in these tissues than
in the nervous. The double processes in each may be thus
tabulated :

* See also Hermann, Habilitations Schrift. Zurich. 1869.

FORMULA FOR NERVOUS AND MUSCULAR NUTRITION. 1 8$

NERVOUS TISSUES (Ganglionic).

Repair of waste.
GENERATION OF FORCE.

DISCHARGE OF FORCE (CEN-
TRAL OK PERIPHERIC IN-
NERVATION).

MUSCULAR TISSUES.

REPAIR OF WASTE.
CONVERSION OF FORCE.

DISCHARGE OF FORCE,

Or, for the first case, we might construct the formula, r -{- F
= D — for the second, R + F= D, Theoretically, we should
presume that the larger letters in the formula were those
covering the widest margin, and hence admitting of greatest
variation, and so far clinical facts abound to justify this pre-
sumption. It is indeed very common at the present day to
ascribe functional nervous disorders to ** deficient nutrition,"
or " excessive waste " of nerve substance. As, however, in
the cases in question, the most complete development of the
disease (/. r., spinal irritation, etc.) remains unattended by
atrophy of nerve substance, not the least anatomical proof
can be alleged of this hypothetical ** waste.*' The clinical
facts express a disturbance in the special function of the
ganglion cell, t, c, in the generation or in the discharge of
nerve force. It is theoretically quite conceivable, although
structural waste of the morphological elements of the cell
were completely repaired, that alterations should occur in
the formation of the lecithine molecule,^ or in the process
of its decomposition, or in the intra cellular molecular circu-
lation, or in the degree of resistance offered by inter cellular
fibres to the transmission of impressions, etc. Indeed, dis-
turbance in the functions of nerve cells must imply altera-
tion of one or more of these processes. To go behind them,

* If we adopt the strongly fortifi(5d hypothesis of Wundt.

l86 THE QUESTION OF REST FOR WOMEN.

and imagine a further alteration in the assimilation or dis-
assimilation processes, i. c, in the structural nutrition of the
cell, as a necessary basis for such disturbance, is to adopt an
hypothesis for which there is, to say the least, no proof, nor
by any means the analogies which justify Wundt's scheme
of nerve functions. We claim, on the contrary, from the
simplest comparison between "functional** diseases of the
nervous system, and the organic diseases resulting in fatty
degeneration, atrophy, and sclerosis, that the generation of
force in nerve cells is very frequently interfered with, but the
repair of waste, in comparison, rarely; and, almost as a
corollary, the disturbance of function results in disorders,
which, however alarming, may be cured ; but the disturbance
of nutrition results in lesions, whose effects, infinitely more
insidious, are generally incurable.

These considerations should already show that there can
be no reason for presuming identity or parallelism between
the activity of the nutrition or function of nerve centres and
of muscles. The current theories of menstruation, however,
which lay great stress upon the generation of force presumed
to be involved in the maturation and dehiscence of the ovule,
do constantly insist, tacitly or implicitly, that in order to com-
pensate for this there must be a corresponding diminution in
the generation of force elsewhere. These theories assume a
spontaneous diminution in the functions of certain nerve
centres, in order to liberate force for the organs of reproduc-
tion, in a manner somewhat analogous to the diminution in
functional muscular nutrition which we have tried to show is
necessary, in order to provide for the surplus material needed
for reproduction. Besides the arguments already adduced in
favor of the latter theory, we may urge the following objec-
tions against the former:

I. During menstruation, even during any period of the
menstrual cycle there is no expenditure of plastic nerve force,
especially is there none in any way comparable to that of preg-

NERVOUS PHENOMENA OF MENSTRUATION. iS/

nancy with which nevertheless it is often half consciously
compared. The analogies between menstruation and preg-
nancy relate to all other particulars rather than this. The
ripening of the ovarian epithelium, and the tumefaction of
the uterine mucous membrane are nutritive phenomena on a
tolerably minute scale ; involving it is true the innervation
of the organs, as do nutritive phenomena in any organs, but
in very trifling excess at one time of the menstrual cycle over
another?

2. The nervous disturbances that so frequently accom-
pany the menstrual hemorrhage, (which only corresponds to
one part of the m enstrual cycle, and that not the most sig-
nificant,) do not imply an ** increased generation of force " in
nerve centres, supposed to preside over the organs of gener-
ation. They constitute, as will be frequently shown, reflex
irritations, that are either expended on the muscular fibre of
the utt^rus, causing local cramps, or on any distant portions of
the nervous system by the medium of the spinal cord accord-
ing to the usual mechanism of reflex irritations. They
are as pathological as the reflex irritations of digestion in
dyspepsia.

3. In the absence of subjective evidence, the vascular tur-
gescence of the bulb of the ovary at menstruation, cannot
be assimilated to the phenomena of erection, nor can condi-
tions of innervation analogous to those of the latter process
be inferred.

Is it possible to arrive at any numerical equivalence be-
tween the factors of which we believe to have indicated the
equivalence, or, of any nearer idea of the mechanism by which
the equivalence may be effected.

To do this we should not rely upon comparison of the aver-
ages of each set of factors, but compare in a series of individ-
ual cases the following groups of physiological facts; the
muscular strength ; the evolution of heat, and its consump-
tion during muscular action ; the number of blood corpuscles ;

l88 THE QUESTION OF REST FOR WOxMEN.

the vital capacity of the lungs ; the elimination of urea ; the
excretion of CO,, and the amount of menstrual blood.

These should be measured against each other during men-
struation, and during the premenstrual, post-menstrual and
intermenstrual periods. As it is, the data at our disposition
are extremely unprecise. In regard to muscular strength, we
have the rather famous measurements of Ouetelet, to which
reference has already been made.* These estimates are made
by means of a dynamometer that measures the strength of
the muscles of the back {force r^nale) then with a dynamom-
eter for the hands.

With the first, Quetelet found, that from the age of seven
to thirteen the strength of the boy to that of the girl was as
14 to 10. From thirteen to eighteen it was as 18 to 10. Of
the man after twenty to the woman of the same age, as 14 to
10, or nearly double. At twenty, the force of the two hands in
the man was 78.6, in the woman 46.6, a difference of 32,
which is proportionately less.

This difference of muscular strength is much greater than
the difference of muscular mass. It implies a greater intensity
of muscular contraction. But this implies a greater con-
sumption of the non-nitrogenous substances whose oxida-
tion supplies the he^t-equivalent of the mechanical force
evolved.' It is this same class of substances, especially the
fats which are utilized in the development of embryonic tis-
sues. In non-pregnant women, there is more fat in the blood
than in men ; in pregnant women the excess of fat is stored
'up in the liver. In both cases it is saved from diminished
muscular consumption. According to Longet, women have
habitually a higher temperature than men. Is less heat con-
verted into motor force ? The more abundant oxidation in
the man, necessitates on the one hand a larger proportion

* Anthropometric, p. 370, 1870.

• Hardy ; Principes de Chimie Biologique, p. 253, 1871. See also Schiff, Fisk,
Gavarret, Ranke, etc., already quoted.

PROPORTION OF BLOOD CORPUSCLES. . 1 89

of blood corpuscles to the plasma of the blood, and a greater
vital capacity of the lungs in respiration. Since the introduc-
tion of methods for counting directly the blood corpuscles,
no other method of estimating them can be relied upon,
except for the most approximate estimate. According to the
older method employed by Andral and Gavarret, Becquerel
and Rodier, Robin,* and Hoppe,' the proportion of blood
corpuscles to a thousand parts of blood, was estimated.
Robin reckons in 1,000 parts of blood, 320 red corpuscles
for a man, and 300 for a woman, that is, the latter should
have one-sixteenth fewer than the former. By the new
method, the number of corpuscles in a cubic millimetre is
enumerated. Now by this method, it has been shown that
a healthy man's blood contains about five million corpuscles
to the cubic millimetre, a woman's four million and a half."

With this diminution of hematics is a diminution in the
amount of air taken into the lungs, the vital capacity of
women as measured by the spirometer being only from two-
thirds to three-fourths that of man's, (Waldenburg,) or
16.7.5 cubic centimetres, for every one centimetre of weight,
instead of 22-24 as in the case of the average man,
(Wintrich).

Now these differences do not correspond. The muscular
force is half, the breathing capacity three-fourths, the num-
ber of hematics destined to carry oxygen from the lungs to
the muscles is nine-tenths of that of man.

It is noteworthy that the proportions between respiration
and muscular force are much nearer approached than are
either to the proportion of blood corpuscles.

This already suggests that while the two first variations
are probably in relation with one another, the latter is inde-

' Le9ons sur les Humeurs. p. 40, 1867.

• Physiol. Chemie.

• This is the calculation of Vierordt. Keyes, (loc. cit.) arrived at the same con-
dnsioiu Malassez gives a lower estimate for the blood of men, 4,500,000.

190 THE QUESTION OF REST FOR WOMEN.

pendent of both. The estimate of the number of blood cor-
puscles, indeed, is only relative to the amount of blood
plasma, and is to be accepted quite as much as a proof that
the plasma is increased, as that the corpuscles are diminished.
On this point, a remark by Robin is perhaps apropos. ** At
the moment of birth, the blood cells (hematics and leucocytes
together), instead of being in the proportion of 320 parts to
680 parts of plasma, may be precisely inverse, that is, 680
parts to 320 parts of plasma. . . . The further back in
the intra-uterine existence the examination is made, the
greater is the proportion of the globules. . . . The reason
is easy to understand. In the foetus the plasma is furnished
entirely by the mother, is apt for assimilation, and only very
little elaborated by the foetus, consequently it is assimilated
as fast as it arrives, so that, so to speak, there is no time to
increase its quantity, proportionably to the increase in the
number of hematics.** — Loc. cit. p. 41. If now in the woman,
at all times liable to the demands of reproduction, a certain
proportion of nutritive plasma remains unassimilated (see ut
supra), it will remain in the blood, in relative excess to the
number of blood corpuscles, and tending, unless appropriated
by the embryo, to accumulate in the circulatory system, to
raise vascular tension, and thus to prepare the way for the
menstrual hemorrhage. The same reasoning should apply
to the "physiological anemia** of pregnancy. From this
point of view, therefore, we might expect to find a relative
dimhiutiofi of blood corpuscles before menstruation, instead
of a rise. From the analogy with the composition of the
blood in pregnancy, we should be led to conclude that,
roughly speaking, the number of hematics furnished the
measure for the energy of muscular oxidation and evolution
of motor force, the plasma, for the abundance of nutritive
material and reproductive force.

It would not be profitable at the present time, and with
the data at our disposal, to pursue this inquiry further;

STATEMENT OF QUESTION. IQI

although many of its details invite investigation. It is better
for the purpose of this Essay, to now turn our attention to
tipplying the theory of menstruation as above exposed
towards the theoretical elucidation of the question : Do
women require rest during it ?

SECTION VI.

APPLICATION.

FROM the review of the menstrual process which has
been given, we are obliged to admit several decided
contradictions between the deductions of theory and the
facts of practice. Thus we have seen that, in the great
majority of cases, when menstrual rest is either advised or
taken, it is made to coincide exclusively with the menstrual
hemorrhage. Yet this period, as Williams justly observes,
is really the least important of all, in the succession of periods
constituting the entire process.

The hyperaemia of the uterine mucous membrane, and
frequently also (though by no means always) of the ovarian
bulb and Graafian which constitutes the so-called "pelvic
congestion," precedes menstruation, /. e'., the menstrual flow,
and, if analogous to pathological congestions, should be a
period of sufficient discomfort and local distress to necessitate
rest. Yet during this period, the majority of women feel
remarkably well, and would be astonished if advised to keep
their bed or sofa. Nor are they recommended to do so by
their most solicitous advisers. On the other hand, the week
succeeding the hemorrhage, if we reason from analogy WMth
pathological hemorrhages,* should be a period of exhaustion,
during which again, exertion would be difficult or even im-

* Other than haemoptysis, after which the patient feels often extremely re-
freshed. The reason is obvious ; the hemorrhage, as in menstruation, has been
prepared for by a rise of vascular tension, that upor. weak nerve centres may
cause irritation and often fever.

PROPOSITIONS ON MENSTRUAL PAIN. I93

possible. Yet in the majority of cases, i, e., of women con-
sidered in fair health, there is then a great capacity for exer-
tion, and feeling of well being ; ** Elle est plus frais, plus
dispos,** to use the French idiom. On the other hand, the
moment when the pelvic congestion is relieved, the height-
ened muscular tension lowered by the onset of the hemor-
rhage, is the time when pain is most frequent, and when, if
ever, the woman seeks repose. Two questions must be
answered, ist, Why should pain ever occur at this time?
2d, What relation exists between the successive phases of
the menstrual process as we understand it, and the variations
in the clinical phenomena presented by women at the periods
corresponding to these phases ?

The following propositions require no argument to be
admitted.

1. In the majority of women, otherwise in good health,
who suffer pain, this begins either with the flow, or a few
hours before, and lasts six, twelve, twenty-four hours ; in
some cases forty-eight, but then always, in the cases we are
considering, in much diminished severity.

2. In a limited number of cases, the woman feels an in-
crease of health, and especially of mental vigor, during the
period of the menstrual flow. (We have several such on our
list.)

3. In the cases of pain, it consists either in cramps, or in
a feeling of weight, and may be very moderate in intensity.

4. Dysmenorrhea, with the above characters, represents
the mildest form, and often scarcely merits the name.

5. In another class of cases the pain has the same dura-
tion, and coincidence with the flow, but is much increased
in severity, the cramps being violent in character, and bear-
ing more or less resemblance to pain in parturition. This
pain generally does not begin until after the flow.

6. In both the above classes, the premenstrual period is
generally one of increased health and energy ; as it is also in

T •%

194 THE QUESTION OF REST FOR WOMEN.

the cases where no pain is suffered at all. In another class,
the patients begin to suffer two weeks, one week, or two
days, before the menstrual flow, from backache, pelvic weight,
or even burning pain in the hypogastrium. Such persons
generally suffer burning pain at menstruation instead of
cramps. The cases are of much graver import than the pre-
ceding.

7. The post-menstrual week is also usually a period of
well being. This condition is not apt to be damaged by the
existence of pain during menstruation, but is very much
affected by excessive flowing, which nearly always leaves a
state of prostration, which often is not recovered from for
several days.

After these admitted statements a few postulates.

1. The variations in the quantity of the menstrual flux
are in relation partly with the degree of individual nutrition
of the woman, but partly also with the rhythmic wave of
supplemental nutrition. It is possible that the latter may be
defective, yet the former good, indeed better, on account of
the deficiency of the supplemental wave. Again, the old
opinion that the menstrual flux was never to be considered
excessive, unless the nutrition or nervo-muscular energy of
the woman were evidently weakened by it, is true. For it
may imply either larger absolute development of the supple-
mental wave of nutrition, or a less demand on the part of the
nervo-muscular tissues from the individual nutrition.

2. There is really no evidence that complete amenorrhea,
/. r., without menstrual molimen, is ever dependent on de-
fective ovulation.* After extirpation of the ovaries, although
menstrual hemorrhage usually ceases, the menstrual molimen
frequently persists. Eight cases have been collected where
menstruation returned after double ovariotomy. (Journal
Obstet.)

* Ahliough Bames, Clinical Lectures, p. 181, enumerates this as a cause and
Althaus (Med. Times, 1874) applies electricity to the ovaries to remedy it.

UTERINE CONTRACTIONS IN MENSTRUATION. I93

In Dr. Thomas' case of normal double ovariotomy for
excessive dysmenorrhea, the operation, which at first afforded
relief, was afterwards followed by a return of periodical pain.
But there is abundant proof of its dependence upon deficiency
in the supplemental nutrition, and its frequent association
with deficiency of individual nutrition, whose original start-
ing point is more frequently an alteration in t\\Q functions of
the nervous system, than in the digestion and hematosis.*

3. Menorrhagia and dysmenorrhea, on the contrary, are
much more frequently to be traced to perversions in the
assimilation of nutritive material by the blood (simple ane-
mia), or in the generation of force in nerve centres (neurotic
anemia).

The cause of the simple spasmodic form of menstrual
pain is as follows :

The increased rapidity of circulation in the walls of the
uterus excites the contractility of the uterine fibres, in virtue
of which the blood is forced towards the free surface of the
endometrium. Rindfleisch' observes that the hypera^mia of
mucous membranes, as of the stomach and intestines, is
largely effected by the contractions of the muscular mem-
branes underlying them. And it has justly been observed
that the parenchyma of the uterus is to be considered as the
muscular wall of its mucous membrane, hypertrophied to
meet the special exigencies of the organ.

In perfectly normal cases, these contractions are slow,
rhythmic, as painless as the contractions of the uterus de-
monstrated to occur during pregnancy,' or of the intestines
in healthy peristaltis.

If, however, the vaso motor nerves of the uterine vessels
become irritated under the increased pressure of blood, or by
transmitted irritation from cerebro spinal centres, unable to

' Though the contrary is the opinion of Beau, as expressed in his treatise on
Dyspepsia.

• Pathologischen Gewcbelehre. 1871. * Snow Beck. Obstetrical Trans. 1873,

196 THE QUESTION OF REST FOR WOMEN.

sustain the increased blood pressure, spasmodic contractions
of blood vessels will take place from time to time, rendering
the circulation of the parenchyma irregular, the fibre here
anemiated then hyperaemiated, inducing therefore spasmodic,
tetanic contractions of the muscular fibre, which cause pain
of various degrees of intensity.* Susceptibility to vaso motor
irritation is in inverse proportion to the stability of function
of the brain and spinal cord, therefore this form of dysme-
norrhea if well marked, indicates deficient generation of force
in the nerve centres, and is frequently, (though by no means
always) accompanied by cramps of the stomach and intestine,
dependent on the same conditions. This form of pain, from
its cause, ceases when the increased tension in the blood
vessels of the parenchyma is relieved by the rupture of blood
vessels in the tumefied endometrium. Hence, in the mildest
form of all, it subsides in from two to six hours. When pro-
longed much beyond the free establishment of the flow, it
shows cither that the vaso motor irritation, once set up, per-
sists after cessation of its cause, as is common ; or else that
in the spasmodic contraction of uterine fibres, the os is fre-
quently closed to the egress of blood. The excess of vaso
motor irritation is a proof of diminished resistance offered by
the spinal cord to the transmission of impressions.

This form of dysmenorrhea may exist from the begin-
ning of 'menstruation, but in such cases, the girls are either
decidedly neurotic, (/. e. with insufficient assimilative power
in the tissues of the nerve centres,) or anemic, i, e. with insuf-
ficient blood to nourish them. These cases are very frequent
in families inheriting consumption. If, however, the anemia
be pushed beyond a certain point, the supplemental wave of
nutrition never rises sufficiently high, to greatly increase the
tension either in the general circulation of the uterine blood

' See Oser and Schlesinger, Schmidt's Jahrbucher. Experiments on Contrac
tions of uterus, induced by closure of the aorta. Also Putnam Jacobi, Note on
nitrite of amyle in dysnienorrhea, Medical Record, 1875.

ANEMIC DYSMENORRHEA. 197

vessels. Such persons, therefore, though feeble, suffer no
pain on menstruation. This is generally scanty ; when pro-
fuse, (in these cases) it indicates a debilitated relaxation of
blood vessels, unable to resist the periodical tension. We
have, as in all vaso motor paresis, reason to attribute this to
paresis of central innervation ; the limit is passed at which
irritation of vaso motor centres is occasioned, and it is re-
placed by vaso motor exhaustion favoring prolonged hemor-
rhage without pain.

These considerations answer in part questions i, 2 and 3,
on p. 143.

But this form of dysmenorrhea is often acquired.* Any
condition capable of determining the requisite degree of
anemia or of neurosis may induce it, and our tables of cases
show a number of instances where the habit of spasmodic
menstrual pain has been acquired under circumstances tend-
ing to produce these conditions. Over-work is one frequent
cause. During excessive muscular exercise (/. e. as compared
to the individual muscular capacity) the blood becomes
watery, ,(Ranke) and thus anemia produced. But on our
tables we have very few cases, (perhaps half a dozen from
factory girls,) when this cause could be alleged. A very
much larger number of persons have been engaged in work
such as is generally described as involving " nervous strain,**
such as teaching. Now ** nervous strain " must mean exces-
sive action of nerve centres, in one of three directions, namely,
intellectual activity, moral emotion, especially anxiety, or
motor force expended in muscular activity. Teaching six
hours a day, (we select this occupation as the one most
numerously represented on our tables, and also on the census,
after agriculture and domestic service,) cannot be said under
ordinary circumstances, to involve any excess of either intel-
lectual or emotional activity. But, when analyzed, we find

' Whether more often acquired than congenital, 1. e, primary, we have not, at
present, data to determine.

200 THE QUESTION OF REST FOR WOMEN.

The backache, so often mistaken for a symptom of uterine
disease, is the typical as well as initial symptom. It is a
marked characteristic of the chloro anemia of puberty, but is
rarely absent from the states of acquired anemia of which we
are speaking. Let us see if the theory of menstruation as
exposed, will offer an explanation of this muscular asthenopia.

The theory of muscular contraction shows that asthenopia
or loss of function may be quite independent of alteration of
nutrition proper, /. e, of assimilation in the muscular fibre.
It is admitted to-day that the sensation of fatigue depends
on the accumulation in the muscle of the oxidized products
formed during the process of muscular contraction. Since
both the oxidations and the circulation of the blood current
which washes away their products, are involuntary move-
ments regulated by the reflex innervations of the muscle, th^
sensation of fatigue may be prematurely determined by alter-
ations in this innervation, especially at the central, /. e. spinal
cord portion of the reflex arc. Exhaustion of the innerva-
tion in this way causes muscular weakness and fatigue. On
the other hand, the innervation remaining intact, the mole-
cular movements of the muscular fibre during contraction,
may be so diminished in energy that all the heat evolved in
the oxidation is not converted into motion, hence the demand
for oxidation ceases before the chemical process initiated by
the influx of nerve force, has been completed. Instead there-
fore of continuing to the ultimate term, the formation of
carbonic acid, the process stops short while yet incomplete,
and partially oxidized material remains, producing the sen-
sation of fatigue. Asthenopia would then be really of muscular
origin, starting from the perverted mode of function of mus-
cular fibre. Many facts of physiological experiment, showing
the degree of independence of muscle and nerve, indicate the
possibility of such an independent starting point, however
obscurely we can represent to ourselves the precise condition
in which it consists.

ENCROACHMENT ON MUSCULAR NUTRITION. 201

Assuming, however, as we are so well justified in doing,
a change in the molecular movements of the sarcous ele-
ments, whereby the energy of muscular contraction as a
whole is diminished, we must seek the cause of this change
in the structure or chemical composition of these elements.
This must be effected by the assimilation and disassimilation
carried on in them ; in other words, by their nutrition proper.
To say that a badly nourished muscle contracts feebly, is
only to state a well known clinical fact.

Let us suppose that the habitual force of muscular con-
traction was diminished by one-quarter from a type standard.
There would be a corresponding diminution in the afflux of
blood to the muscles — thus also one-quarter. Suppose, fur-
ther, that the habitual margin left for periodical reproductive
diminution in the energy of muscular function was one-eighth
of the whole amount ; it would therefore, in the given case, be
one-eighth of three-quarters (-^ of f = •^j)y or about one-tenth
instead of one-eighth. But this amount may be insufficient to
liberate the amount of blood required for the reproductive
node,^ that is, for menstruation. As the necessity for repro-
ductive nutrition, once established, will, for a long time, take
the precedence of individual nutrition,' the deficiency must
be made up, and is made up by diminishing the afflux of
blood and nutritive material required, not only for the func-
tions of the muscle, but for the repair of waste in its fibre.
Hence insufficient nutrition of muscular fibre, and then, by
the vicious circle common to all pathological processes,
diminished contractility or function, pain in function, especi-
ally of the muscular fibres of the uterus, diminished afflux
of blood for further nutrition.

A suggestion in passing. It is known that in vegetables
reproduction ceases unless the individual nutrition be devel-

' The term " node " is of course used here from the analogy with plants.
• WTiich, for the human species, is equivalent to saying that profoundly ane-
mic women will continue to menstruate and bear children.

2C2 THE QUESTION OF REST FOR WOMEN.

oped to a certain standard, while in animals reproduction
continues long after profound deterioration of the individual
nutrition. Is not this because in the former, material for
reproduction can only be saved out of the material for indi-
vidual nutrition, while in the latter, the reserve is formed by
the material that would be used in functions?

From the above, we should conclude that the circum-
stance which mainly favors the deterioration of muscular
nutrition by the supplemental reproductive wave, is the
original feebleness of muscular function. Practically we find
that the habit of disordered and painful menstruation is more
frequently associated with habits of feeble muscular exercise
than with any other one circumstance.

Into the effects of overwork upon the nervous apparatus
of women, in connection with menstruation, it is much more
difficult to enter, because the normal relations between the
two are much more obscure. The facts so often alleged in
profusion to demonstrate a peculiarly intimate relation, can,
as we have seen, all be classified as cases of reflex irritation,
in which impressions have been transmitted to nerve centres
whose power of resistance has been abnormally diminished.
** The neuroses of menstruation," on which Bcrthier has
written a voluminous monograph, all belong to this class.
Hysteria, convulsions, paroxysms of insanity, simple out-
bursts of ill-temper, headaches, cramps, catalepsies, phenom-
ena however extraordinary or however multiplied, add
nothing to the principle already contained in the simplest.
This principle is» that any new vital action, /. r., a process in
any organ or tissue necessarily involving vascularization and
innervation, may become the starting point of hnpressions
that, when transmitted by centripetal nerves, will be extin-
guished in nerve centres of normal power of resistance, but
will be diffused in centres of diminished power of resistance.
Or again, with normal resistance in nerve centres, a per-
verted vital action on the periphery, irritating nerve filaments,

REFLEX DISORDERS OF MENSTRUATION. 203

may again cause centric irritation. The case ' of menstrua-
tion is precisely paralleled by that of teething. In men- "
struation, the second condition is fulfilled either in the
obscure disease known as ** subacute ovaritis/* where the vas-
cular turgescence accompanying the rupture of the follicle
becomes a source of irritation to the ovarian nerves, or else,
in the various conditions of irregular circulation, or imperfect
nutrition or contractility of the muscular fibre ^f the uterus,
which renders the afflux of blood towards the cavity a source
of irritation to the nerves of the parenchyma.

The essential precaution against such reflex disorders
consists in obtaining such an organization of the central
nervous system as will raise its povver of resistance to peri-
pheric impressions to the normal standard. This is chiefly
done either through inheritance, or through influences brought
to bear during childhood. Much less can be effected in adult
life, especially in relation to regularly recurring impressions
at long intervals, like those from the uterus and ovaries at
menstruation.

It appears evident, therefore, that the functional* condi-
tion of the muscular system at puberty, and the organic con-
dition of the nerve centres, powerfully influence the regular-
ity and tranquillity of the menstrual process. Disturbance
i$ acquired when these conditions have been determined' by
the given influence; for instance, by overwork. Thus:

1. In work involving much muscular exertion, or exer-
tion long time repeated, the supplemental wave of nutrition
may be unable to establish itself out of the small residue of
nutriment left over from that consumed in the function of
the muscles ; it then will be derived from their nutrition, and
then the chain of sequences already noted * will be initiated.

2. In work involving much fixed attention, and perhaps
the activity of motor centres in the brain, the generation of
force in the nerve centres seems liable to become impaired,

* See p. 201.

204 THE QUESTION OF REST FOR WOMEN.

and, coincidently, their resistance to impressions diminished.
In this case, amidst much which is obscure, we can distinguish
the general fact that the repeated expenditure of nerve force
finally renders the generation of force difficult. All excita-
tion is so rapidly transferred to the periphery of ganglionic
cells, that too little remains to store up force in the centre.

That the ganglionic nerve cells of women seem, on
the whole, to be more easily exhausted than those of men,
so that prolonged effort requiring prolonged generation of
nerve force is more readily followed by collapse, is a fact
that cannot be doubted. That this peculiarity must be in
some way dependent upon their reproductive nutrition is
also certain, but the exact relation between is not easy to
determine, even hypothetically. There is, however, much
reason to believe that the relation exists through the medium
of the muscular system. As the vito-chemical processes
carried on at the periphery of the nervous system in mus-
cular and other tissues are constantly regulated by the influx
of forces coming from the nerve centres, so the generation
of force in these centres is constantly influenced by the
arrival of impressions coming from the periphery, and by
none more than those caused by muscular contractions. The
influence of systematic muscular exercise, passive or .active,
upon the nerve centres, is most strikingly manifested in many
well known cases of nervous disease, as, to a certain extent,
hemicrania, and still more notably, spinal exhaustion. The
feebler muscular contraction in woman, therefore, should be
expected to correspond to a diminished quantum of force
generated in the centres connected with centripetal muscular
nerve fibres.

For reasons already urged, the peculiarities observed in
women's power of exertion and attention are theoretically
explained by such peculiarities limited to the motor centres.
They do not imply, and there is much difficulty in admitting, a
primary extension of the rule to sensory or intellectual centres.

MUSCULAR HYSTERIA. 205

An apparent exception exists in the case of peasant
women with strongly developed muscular systems, who arc
yet not unfrequently liable to hysteria in its most violent
convulsive form — liability which proves greatly diminished
resistance to the diffusion of impressions in the nerve centres.
We have ourselves noticed such muscular hysteria, whose
paroxysms generally coincided with the menstrual period, in
a girl whose mental development was arrested on the borders
of idiocy; and such cases are common. These must cer-
tainly all be referred to an original imperfection of structure
of the nerve centres, involving the sensory and intellectual
centres to a much greater extent than the motor. This is
positively proved by the large amount of power possessed
to sustain prolonged and intense motor exertion, and the
deficiency in the power to resist sensory impressions, or to
generate or combine ideas. The condition of such women is
precisely the inverse of that typically characteristic of their
sex.

To say that the quantum of force habitually generated
in a given time in one nerve cell, is less than that in another,
is to say that the periods of expenditure of force must be
shorter for the second than for the first, and the interval
of repose longer, in order that an identical amount of force
may be obtained from both. The case is analogous to. that
of a feebly contracting heart, when by the administration of
digitalis, which prolongs the intervals between the contrac-
tions, a greater amount of force is accumulated to be ex-
pended at each of them.

The practical inference to be drawn from these considera-
tions, in regard to the adjustment of female work to the
reproductive necessities of her economy, is, that this should
be constantly intermittent, not at long intervals but at short.
Since the menstrual flow does not itself constitute the repro-
ductive demand made upon the individual nutrition, but
only expresses the result of that demand, since the latter is

206 THE QUESTION OF REST FOR WOMEN.

made constantly, and only its effects accumulate in a rising
curve, nothing would be gained, but much lost, by a single
intermittcnce of work during the few days of the menstrual
hemorrhage, the strenuousness of the rest of the month
being left unchanged. From all the facts hitherto reviewed,
we can find none to indicate that such a method of rest
would prcvejtt the occurrence of pain or breaking down in
health, in any peculiar way, or different from what might be
expected of frequent vacations taken at any other time.
Nor from our tables of cases, do we find that the habit of
resting exclusively at this time, frequently acquired when
menstruation habitually became painful, ever exercised any
influence in removing the pain. This might be removed by
other agencies ; it would always be rendered more tolerable
by repose, but there is nothing, at least in* the evidence
before us, to show that excliisivety menstrual rest is capable
of exerting a curative influence. The kind of rest needed by
women consists in interruptions to employment every two
or three hours, not every three or four weeks.' The immense
preponderance of domestic service over every other form of
feaiale labor, we mean of labor demanding the same degree
of capacity, is in itself an indication of preference for work
involving more hours but frequent interruptions, over work
more compactly arranged, in an unbroken series of hours,
though these terminated earlier. On the other hand, in
higher employments, eight hours steady work is felt as a
severe burden, when we believe (we are not at this moment
prepared to absolutely /r^^i^^ it) two sessions of work, of four
hours each, would entail little fatigue.

We do not, therefore, find it necessary to assert, even
theoretically, that since muscular power is diminished in

* Thackrah, in his pioneer treatise on the influence of the professions upon
health, mentions the marked improvement effected in the condition of the opera-
lives in a certain factory after the habit of an afternoon lunch had been intro-
duced (1837).

women's capacity for muscular work. 207

women, in correlation with their immense capacity for repro-
'duction, that therefore they should never be allowed to per-
form any muscular work at all. On the contrary, as in the
most abstract sense movement has been shown to be the one
principle out of which all forms of existence were differen-
tiated ; as motor force has been shown to be, in animals, the
reserve or balance fund, by which differences, and especially
differences between the two sexes, are brought into equilib-
rium ; so in the female sex, does the muscular nutrition con-
stitute the main reserve, out of which may be met all the
demands of reproduction, without detriment to the individual
life. It is well known that muscular exercise increases mus-
cular nutrition. It increases the sum of nutritive material
stored up in the muscles, ready at any moment to be appro-
priated, either for the evolution of motor force in muscular
contractions, or for the development of the supplemental
wave of nutrition, destined to terminate after one month in
menstruation, or after nine months, in parturition. The
more the muscles are exercised, the larger their mass, hence
the larger the amount of nutritive material stored up in them
for this double disposition : hence the less the danger that
the development of the supplemental wave shall encroach
upon the nutriment necessary for the muscles or the nerve
centres. The consequences of excessive muscular action, /. c,
what is beyond the assimilative capacity of the muscular
fibres to repair, have been several times referred to in the
preceding pages. Such consequences are undoubtedly in-
curred among the working classes of Europe, though less
among the agriculturists than might be expected. In them,
muscular nutrition seems to invariably increase in exact pro-
portion to the demand for muscular strength ; and whoever
has ever watched the female porters at Boulogne handle
trunks that gentlemen travellers would hesitate to lift, may
doubt whether there be any limit to the development of

208 THE QUESTION OF REST FOR WOMEN.

muscular power in female peasants.' The brutishness of the
nervous system in these persons suggests that in them the
entire activity of the nervous system had been concentrated
on the motor centres — result certainly most undesirable.
But in this country, the danger is certainly the other way.
A cardinal weakness is left in the basis of our society by the
absence of peasantry and of peasant blood — weakness only
to be compensated by a strenuous cultivation, to which our
country people have not attained. Little work is here
attempted that is beyond what should be the standard of a
healthy woman's strength, while very much is declined that
is unquestionably within its compass. The defects in the
industrial or other work occupying our women, lie, not in
the degree of force required for its accomplishment, but in
the prolonged sessions during which the force must be ex-
erted, or in the constrained positions it necessitates. What-
ever posture interferes with the free return of venous blood,
especially from the pelvis, is injurious to a woman. Hence,
of course, long continued standing.

But, without permitting ourselves to speculate on the
probabilities of over-work among the mass of women, and
confining ourselves to our personal statistics, we find that on
the one hand a certain number (32, or44j per cent.) acquired
menstrual pain without losing good general health, which is
contrary to the series of pathological processes above detailed ;
and on the other hand, that among those in whom menstru-
ation became painful, the number engaged in fixed employ-
ment was decidedly less than the number having no employ-
ment at all (31 per cent, against 52 per cent, unmarried, p.
61). Of course in the latter cases, the question of methods
of work or over-work do not come up. What circumstances
should make so large a proportion of persons suffer during a

* " Mighty daughters of the plough,
Stronger than men."

MENSTRUAL PAIN INDEPENDENT OF OVERWORK. 209

menstruation, who had not been predisposed to such suffer-
ing by congenital or hereditary conditions ?

Since menstrual pain, at least of the character, duration
and intensity that we are now considering, is so frequent a
symptom of deterioration of general health from any cause,
and since in the wear and tear of existence, women as well as
men are exposed to the trials, moral and physical, whose
repetition is destined to ultimately exhaust the sum of vital
resistance, it is to be expected that its occurrence would often
have no more special significance than the occurrence of dys-
pepsia or headache in either sex. But in addition there is
one special condition represented in our tables, namely, celi-
bacy. By reference to the tables, it will be seen that the
proportion of married women who learned to suffer at men-
struation was 1 1 per cent., while that of unmarried was 84
per cent. (p. 125.) The influence of celibacy is of the utmost
importance in estimating the health of adult women, es-
pecially in the upper classes, but this influence, which has
been frequently signalized by gynecologists, is very much
neglected by hygienists and sociologists. The influence works
in three directions.

I. In all the social classes in which marriage is considered
the only possible or at least the only desirable career for
women, no other resources are accumulated, and celibacy
implies a social failure, for which exists hardly a pretext of
compensation. This is all the more depressing to women on
account of their habitual dependence upon social opinion,
and slender habits of personal resource. To this general
cause of depression must often be added the personal disap-
pointments which may have been the proximate cause of
celibacy. Depressing moral emotions always tend to inter-
fere with the nutrition of the nerve centres that constitute
the organs of thought,* and then':e secondarily of other centres,
and of the blood.

* We could allege many instances of this. Sec Tuke, Influence of Mind on Body.
M

2 TO THE QUESTION OF REST FOR WOMEN.

2. The rhythmic waves of nutrition which, in the non-preg-
nant woman, rise and fall in monthly periods, are destined
by tne necessities of reproduction, to be interrupted from
time to time, and be replaced by the longer system and more
powerful nutritive wave of pregnancy.

In a normal pregnancy, this follows precisely the type of
the mensual waves, that is, it starts from a minimum point,
both in the nutrition of the embryo and of the mother, imme-
diately after conception, and rises to a maximum just before
parturition. We have seen that at this time the assimilable
blood plasma is the most abundant relative to the corpuscles,'
the vascular tension, the highest, the excretion of urea most
abundant, muscular force alone is diminished,' as if by ex-
perimental magnifying of the minute diminutions effected
for menstruation. In pregnancy therefore holds true, and on
a larger and more important scale, the remark we have made
in regard to the nutritive wave preparatory to menstruation,
• namely, that its effects transcend the limits of the supple-
mental nutrition, and are experienced by the individual tis-
sues of tjie mother. The reverse may be true of course, and
after a certain number of pregnancies, the reproductive wave
is liable to be maintained only at the expense of the maternal

* Whence their relative diminution.

' This is not the place to show as we think might be done, that a large amount
at least of apparent intellectual inferiority in women is due to deficiency of mus-
cular tonicity. Without»this, there is none of the feeling of elasticity and enter-
prise that is as requisite, nay more so, to pursue a chain of thought, as to accom-
plish many physical actions. All intellectual actions require muscular actions for
their expression. The maximum is in scientific investigations. We think it not too
bold a generalization to assert, that the antagonism held by many to exist between
the intellectual capacity and reproductive force in women, and which in a certain
sense and to a certain extent exists, does so through the medium of the muscular
system and muscular energy. Development of the latter alone, merely leads to
more fertile reproduction, a.i in peasant women. But the systematic development
of muscular force, in connection with systematic training of the nerve centres of
intelligence and will, slujuKl greatly increase if not the amount of intellectual
force generated, at least ver}' largely the amount of it that is made effective.

MENSTRUATION AND PREGNANCY. 211

nutrition/ But these cases are pathological. It is note-
worthy that they are much more frequent after the multiple
pregnancies of healthy women, than at the first pregnancy of
a delicate one; chloro anemic girls frequently become fat,
strong and rosy, during their first, pregnancy, to fall into
anemia again it is true, during lactation, but not unfrequently
to have their health permanently improved. The reproduc-
tive force for women, as for plants, is fixed not only accord-
ing to the race, but according to the individual. The power
of voluntarily increasing the achievements of this* force, by
multiplying at will the number of pregnancies, is only appar-
ent ; for, as we have seen, if the resources of reproductive
nutrition or force are exhausted, they are not regained, but
eked out at the expense of the maternal organism. Con-
versely, the power is very limited of maintaining the nutrition
of this organism, without reference to the supplemental wave
of nutrition, and to the occasional stimulus of pregnancy, in
view of which the entire economy has been constructed. It
would seem as if in the uninterrupted recurrence of menstru-
ation, the lesser supplemental wave of nutrition gradually
encroached on the individual nutrition ; precisely as, in a too
frequent recurrence of pregnancies, we have seen to be the
case. Our attention has been frequently called to the fact,
that in unmarried women between the ages of twenty-eight
and thirty-five, living apparently in the most healthy and
admirable conditions, is often observed a general failure of
strength without any apparent cause. Unless some special
predisposition exists, no special disease is developed, (in the
case we are considering,) but there is loss of flesh, of muscu-
lar strength, of mental energy, diminished appetite, pallor,

* Duncan shows that the mortality of the ninth childbirth rises to the level of
that of the first. The physical conditions of many women at a ninth pregnancy,
which favors so many accidents, uterine inertia, hemorrhage, transverse positions,
septic absortion, is however often reached much earlier, even at the fourth or fifth.
The essence of the condition lies in the complete exhaustion of muscular tonicity.

212 THE QUESTION OF REST FOR WOMEN.

backache, anemic blood, often neuralgia, often dyspepsia.
In these cases menstrual disturbance is often entirely absent,
but at other times the milder form of spasmodic dysmenor-
rhea supervenes. After passing through a period of three,
four or five years in this condition, the health gradually im-
proves, with apparently as little reason as it had deteriorated.
We have acquired the habit of calling these cases, " pseudo-
pregnancies." They are sometimes observed much earlier,
three or four years after leaving school or college, when attend-
ance has been prolonged till twenty or twenty-one, and it is
rather the fashion then, to attribute them to overwork at
college. But when occurring only some time after the close of
college life independent of any influence of adverse circum-
stances, of local disease or hereditary predisposition, we believe
they are to be explained by the lack of stimulus that should
be derived from reproduction.

So predominant is this necessity, that the same condition
of health may be seen in the women who are married but
sterile. These however, are more prone to local disease of
the uterus or ovaries. While assigning to the necessity for
reproduction, the predominant place in the female organism,
the importance to general nutrition of the physical stimulus,
derived from the exercise of the sexual functions must not
certainly be overlooked.

It cannot be said, that it is overlooked by the physicians
who have written on diseases of women ; but many arrange-
ments of society in modern times, seem to have been planned
on the assumption of almost the complete absence of such
necessity.

3. The last effect of celibacy and sterility we have to con-
sider, is that on the uterus and ovaries. In this respect while
much truth has been perceived, many exaggerations and mis-
statements have been uttered. Thus Barnes says, "That the
activities of the ovaries, uterus, and mammary glands, are
intended to periodically relieve each other by the alternations

CONDITION OF STERILE UTERUS. 21 3

of ovulation, pregnancy, and lactation." We have seen how-
ever, that the development of ovules by no means necessarily
ceases during pregnancy, and the activity of the mammary
glands is of too short duration to require relief. The cessa-
tion of menstruation during lactation however, does preserve
the uterus in a more quiescent state than when its walls are
subjected to the monthly afflux of blood, even though that
only passes through them, and does not accumulate there.
This period of quiet, necessitated after the extra nutrition of
pregnancy, is probably desirable on other grounds, as exclud-
ing for awhile the liability to stasis and congestion, into
which the menstrual afflux may be converted. King's idea,
already quoted, that the non-pregnant uterus begins to suffer
atrophy by sclerosis, because not permitted to enter upon its
functions, is unsupported by any fact. But the suggestion
seems to contain the germ of an important truth that a uterus
which never has been impregnated, remains permanently in a
rudimentary condition relative to its type, and hence par-
tially unfit to meet the exigencies of a period of life at which
it is destined to be more highly developed.

The degree of deficiency, however, can only be slight, as
may be seen by comparing with some other imaginary arrest
of development, such, for instance, as should make the milk
teeth persist in adult life. Nevertheless, in feeble constitu-
tions, or under special influences, this degree may count for
much. To speak precisely : we have seen that normal men-
struation requires a rhythmic painless contraction of the
muscular fibres of the uterine wall, by means of which the
blood shall be propelled regularly towards the cavity of the
uterus. If now, from imperfect vitality or regressive struct-
ure of these fibres, their contractility be deficient, the blood
will accumulate in the parenchyma of the uterus, causing
congestion of the body of the uterus. This disorder is cer-
tainly much more frequent in sterile women, whether married
or unmarried, than any other one uterine complaint; and

214 THE QUESTION OF REST FOR WOMEN.

admittedly more so than in women who have borne children,
in whom disease of the cervix predominates.* Such deficient
contractility of uterine fibre is the cause of that form of men-
strual pain which consists in pelvic weight and heaviness.
It is equivalent, in the menstrual cycle, to the uterine inertia
of the parturient cycle, which is the cause of so many, and
sometimes such terrific, disasters.

In addition to this deficient contractility of uterine fibre.
Chapman ' points out that from the density and resistance
of the parenchyma of the nulliparous uterus, any undue
accumulation of blood must cau^e much more irritation than
in the yielding tissues of the muciparous uterus, from
greater compression of nerves. Moreover, the blood is more
likely to be " dammed up towards the ovaries," and so call
into fiendish activity the normally obtuse sensibility of these
organs. If, under these circumstances, the complete regres-
sion of the menstrual decidua be arrested, it will persist as
the sensitive, hyperaemiated endometrium of endometritis.
Corporeal endometritis and ovaritis are diseases again, which
relatively to cervical inflammation, are admitted to be very
much more frequent in sterile women than in others. Out
of thirteen cases of uterine disease in nulliparous women,

other than functional, or dependent on congenital predisposi-
tion or defects of structure, which have recently fallen under
the writer's observation, there were nine such cases.

From this review of the possible consequences of celibacy,
it must be evident that they must be taken into account in
every estimate made of the working capacity of women, and
that, when a woman engaged in any employment, deteriorates
in her general or uterine health, it is necessary, before
ascribing the breakdown to the work, to carefully eliminate
the influence of this wide-spread cause of evil.

It happens, moreover, that in this country the women who

* Cases of subinvolution of course excepted, and results of prolapsus, etc.

• Diseases of Women. New York, 1874.

CONGENITAL DYSMENORRHEA. 21$

escape these dangers by marriage and childbearing, do not
utilize their increased vitality in labor other than domestic.
We have seen that one-seventh of the married women of
Great Britain do work.

Fortunately in practice, and as shown by our statistics,
many of the evils threatened by celibacy are never really
produced, and to this, as to other conditions imposed by the
social organism, the human organism shows a marvellous
power of adapting itself. As already noticed, th*ese consider-
ations in regard to the pathological influence of sterility are
of course not intended to shut out of sight the morbid con-
ditions that may result from parturition. But these are
foreigato our subject, which is confined to menstruation in
women presumably healthy.

In regard to other causes of acquired menstrual pain,
such as sudden suppression of the flow through exposure to
cold, nervous excitement, etc., it is unnecessary to say any
thing in this essay, for so much has been said elsewhere. Of
course all influences capable of suddenly checking the uterine
hemorrhage, can only operate during that period of the men-
strual cycle. Such sudden suppression may unquestionably
become the starting point of chronic uterine congestion or
inflammation. But these accidents are confessedly due to
causes acting suddenly, and exceptionally, to unusual' emer-
gencies, in a word. Hence again, they have little to do with
the question of habitual occupation or work.

We have dwelt so long upon the first form of menstrual
pain, that we may pass quite cursorily over the others. In
regard to the second spasmodic pain of very great intensity,
setting in with the first establishment of menstruation, it is
certain that this depends, in the great majority of cases,
upon local anatomical conditions, interfering with the egress
of blood from the uterus. These are well known to be,
stricture of the os flexion, deformity of the cervix. They
nearly always imply a defective development of the organs of

2l6 THE QUESTION OF REST FOR WOMEN.

generation, except in a few cases where a local peritonitis,
preceding menstruation, has caused flexion by means of
uterine adhesions. One of the most severe cases of primary
dysmenorrhea represented on our tables, is that of a young
German servant, in whom this accident had occurred. Out
of six cases of stricture of the os without flexion, all nulli-
parous (two married and four unmarried,) women, in three the
uterus measured less than six centimetres in length. In one
of these cases (married and sterile), there was no pain at
menstruation, because (probably) this was so scanty. The
patient was remarkably small, the deficient development of
the uterus seeming to be shared by the entire physique. In
another, on the contrary, the patient was remarkably tall,
but preserved a certain childishness of character and appear-
ance. Here the development of the organs of generation
had remained behind that of the rest of the body. It is well
known that after menstruation has persisted during some
years, while the os is contracted, congestion, inflammation,
flexion, or even hypertrophy of the uterine body, is frequently
induced by the violence of the repeated menstrual efforts at
expulsion. Even spasmodic stricture, existing during the
first years of menstruation in the neurotic cases already de-
scribed, may, by inducing undue tumefaction of the endome-
trium, entail the results of organic stricture. The same
result, from undue hyperzemia of the uterus. It is the latter
condition, and that of organic stricture or of congenital
flexion, which most often explain the dysmenorrhea in young
girls of otherwise sound health, and who had passed a vigor-
ous childhood, but who are too often destined to break down
after puberty as miserable invalids. Unfortunately the pre-
cise cause of these anatomical deficiencies upon which such
grave consequences will depend, at present escapes us, so
that the prophylactic measures that might be carried out
during childhood, and which are so efficacious against other

CONGENITAL DYSMENORRHEA. 21/

forms of dysmenorrhea, are here too often powerless.' * But
these cases are very frequently cured by marriage, when con-
ception takes place, which is by no means always hindered
by the same conditions which in other cases may appear to
be the sole cause of sterility. If the marriage takes place
early enough, the uterus may continue to develop after it,
and hence the results of its imperfect development gradually
disappear. But when this does not occur, or when celibacy
or sterility exclude the natural cure of the- consequences of
premature menstruation,' we still possess efficacious resources
in medical and surgical treatment. The introduction of
various methods for treatment of stricture and flexion that
have only recently been popularized, is a fact that should
radically change the lives of thousands of women.* Of
course there are, as it is superfluous to observe in this place,
many cases where such treatment is quite unavailable, but
the appropriate cases are really extremely numerous, and
success of treatment is often proportioned to its early date.
Each such patient restored to health by a technical opera-

* The large proportion of cases noted in our Table of primary dysmenorrhea
where the education was limited to "common English," shows that these cases
abound in classes of society where the childhood is less cared for than ift wealthier
classes, and less nutriment provided for the growing body.

' Except as all measures lending to secure an equable development of the
body may influence the special development of the uterus.

* Premature, that is, in comparison with the development of the uterus. It is
very noticeable that in peasant girls, if somewhat chloro anemic and ill devel-
oped, menstruation is often delayed till eighteen or nineteen, and then sets in
without pain ; but in the upper classes, especially of girls living in cities, while
the general nutrition of the body is still imperfect, and its development incom-
plete, menstruation nevertheless occurs at the usual age, but with great suffering.
Here it is evident that the reproductive system is forced into a precocious devel-
opment as compared to that of the individual, even although its establishment
appears to be at the most normal time. Hence certainly many cases of organic
primary dysmenorrhea.

* As decidedly as Donder's treatment of hypermetropia by convex glasses has
changed the existence of thousands, who were formerly condemned to disappoint-
ment or misery by the vague diagnosis, " weak eyes."

2l8 THE QUESTION OF REST FOR WOMEN.

tion, is a permanent witness to the folly of attempting to
explain, still more 'to rectify, women's sufferings by senti-
mental and empty generalizations on the abstract nature of
the female sex. It would be as rational to treat any other
infirmity dependent on anatomical imperfections upon prin-
ciples derived from Pascal's lofty aphorisms concerning the
nature of man !

Finally for the purpose of this essay, it is most important
to notice, that in this class of cases, rest during menstruation
is generally necessitated, and the patient has no choice in the
matter. But on the other hand, that such rest has no influ-
ence in preventing a recurrence of pain, or the development
of the usual train of morbid symptoms. All that can be said
is, that uterine congestion may be aggravated by exertion,
and this consequently is to be avoided. The patient is not
a type of a menstruating woman, but a sick person, and to be
treated, when possible, accordingly.

Referring now to the sixth proposition on p. 193, we en-
counter a third class of cases, of much deeper pathological
significance. In these, premenstrual pain exists, and the
menstrual pain is burning, not cramp like. In such persons
it is certain that the hyperaemia of the uterine ovarian plexus,
demonstrated to precede menstruation, is either excessive,
or the innervation of uterus and ovaries so perverted that
even the normal afflux of blood and increased rapidity of
circulation causes irritation instead of the normal stimulus ;
or the assimilated capacity of their tissue elements is so de-
pressed, that these arc unable to appropriate increased nutri-
ment offered by the increased blood supply, and hence here
as elsewhere, increased blood pressure, unaccompanied by
increased nutritive or functional activity of the tissues in
which it exists, causes pain. We have already noticed some
of the results, if the motor force, the contractility of the
uterine fibres, fail to be temporarily increased by the tem-
porary increase in the energy of their circulation. Jf the

PREMENSTRUAL PAIN. 219

deficiency be carried farther than in the first class of cases,
blood accumulates in the uterine walls instead of being pro-
pelled towards the surface of the mucous membrane, hence a
real congestion, instead of the superficial hyperaemia which
is normal. According to the intensity with which these
causes operate, we have all degrees of morbid states, from
simple congestion to chronic metritis, endometritis, ovaritis.

The intermenstrual pain, beginning two weeks before the
menstrual period, has been associated by many with the com-
mencement of periodical ovulation. It seems indeed probable
that wherever the parenchyma of the ovary is morbidly
hyperaemiated, as in this class of cases, that the ripening of
the Graafian follicle would have the same effect as the growth
of the tooth follicle in a hyperaemiated gum. Although we
cannot admit pressure upon the peritoneum, yet pressure upon
the stroma, perhaps from over distension by an excess of
Liquor folliculi or undue prolongation of the period preceding
the rupture, is theoretically capable of inducing such irritation.
The analogy between the tooth follicles and the Graafian
follicles is great, and the irritation that may be produced
coincidently with their development on the nervous systems of
the woman and of the child, offer many points of resemblance.

From what we have said before, it is evident that we do
not admit a precise coincidence between this special time of
the intermenstrual period, and the maturation of any one
Graafian vesicle as often as has been supposed. But from the
evidence before us, it seems at least not improbable, that in
certain individuals this coincidence is exact, and that this
peculiar premenstrual pain depends not only on the utero
ovarian hyperaemia, (morbidly converted into congestion) but
also on morbid development of an ovule.

All these symptoms indicate utero-ovarian disease of
very varying degrees of severity, but all requiring treatment.
It is in these cases that rest is most imperatively needed, pre-
cisely because it is most apt to be neglected in all cases where

220 THE QUESTION OF REST FOR WOMEN.

the pain is not extremely severe. It must never be forgotten,
that the significance of menstrual pain is less in proportion
to its degree, than to its kind, its duration, and its cor-
respondence with certain stages of the menstrual process.
Six hours' violent cramp, if unconnected with organic defect
of the uterus, is of less importance than moderate endurable
pain, which begins a week before the menstrual flow, con-
tinues throughout it, and leaves the patient for several days
bruised and fatigued. This latter indicates nutritive disease,
although possibly of a low grade.

There is another form of premenstrual suffering that is en-
tirely different from the above described. It consists, not in
a local pain, but in general uneasiness, excitability, often head-
ache, dyspepsia, or even fever. These symptoms depend upon
the increased vascular tension, and increased blood pressure
upon nerve centres possessing deficient powers of resistance.

These effects of the general rise of the vascular tension
resemble the local phenomena previously described as de-
pendent on the local rise of tension in the blood vessels of
the pelvis. They are identical with the symptoms observed
in many cases of amenorrhea, where the supplemental wave
of nutrition seems to rise high enough to increase the gen-
eral vascular tension, but not enough to rupture the uterine
blood vessels ; or where this is rendered impossible by defi-
cient development, or deficient fatty degeneration of the
menstrual decidua. Two of our cases of prolonged amenor-
rhea showed the effects of blood pressure on nerve centres,
excessive relatively to their power of resistance, in a very
marked manner. In one of these cases, the girl had suffered
from severe chorea every summer for three years in succes-
sion, from the age of thirteen to sixteen. She menstruated
from fourteen to fifteen, afterwards once at eighteen, then
not again, except once while under treatment, until twenty-
two. She was neurotic, and extremely fat, with the anemia
characteristic of fat girls. So long as menstruation was not

INCREASED MENTAL ENERGY AT MENSTRUATION. 221

established, she suffered extremely from tympanites of the
bowels, rapidly developed after eating. After some entirely
unsuccessful treatment, including electrical applications,
leeches were applied once a month to the cervix uteri. On
each occasion, for three months in succession, the bleeding
from the leech bites ceased in a few hours, to be followed in
two or three days by a regular hemorrhage. From the first
occasion on which this occurred, the tympanites ceased, and
the superfluous fat began to rapidly diminish.

In another case, where menstruation was regular, the
patient had also suffered from chorea, indeed from the age
of ten to that of fourteen without interruption. For ten
days before menstruation she habitually suffered from tym-
panites, headache, flushes, ringing in the ears, etc. As soon
as the flow set in, all unpleasant symptoms disappeared, and
she felt extremely well. She had no trace of utero ovarian
disease, but at the time the above symptoms were detailed
to me, suffered from cardiac hypertrophy and double valvu-
lar disease, the result of two attacks of rheumatism. Here
two conditions of distress existed, the cardiac hypertrophy,
exaggerating the normal increase of tension, and the imperfect
nutrition of the nerve centres, already indicated by the chorea.

On the other hand, it is in a normal, or even slightly
anemic condition of the nerve centres, that an increase of
health and energy is experienced during the premenstrual
week. This is true, although at the same time the most
complex nutritive processes are being effected in the uterus,
and sometimes in the ovary also. This fact alone demon-
strates that, in a complex organism, the general law of
balance between functional activities of different organs does
not imply that temporary increase in the nutrition of one
must determine a deficiency in the nutrition of the others,
sufficiently marked to b'e perceptible to consciousness. In cer-
tain cases of impaired nutrition of nerve centres, unaccom-
panied by vaso motor paresis, or, therefore, by menorrhagia

222 THE QUESTION OF REST FOR WOMEN.

(such conditions frequently constitute the basis of hysteria), the
increased feeling of energy begun during the premenstrual week
is extended throughout the menstrual flow. We have related
the history of one such case where this circumstance was
extremely marked. The increase in mental energy in such
persons is often remarkable, and offers a miniature resem-
blance, on account of its etiology, to certain forms of ** circular
insanity." For the nutrition of the brain centres is habitually
below par, and their activity consequently weak ; but under
the increased blood pressure and rapidity of circulation of
the pre-menstrual period, this is raised to normal intensity.
In the pathological cases, the activity, raised above the normal
point, and perverted, constitutes mania. Moreau (Psycho-
logie morbide) relates cases, observed in both sexes, where
periods of semi-idiocy regularly alternated with periods of
considerable literary talent. During the first, the circulation
was sluggish, during the second, accelerated.

CONCLUSIONS.

HAVING exhausted the material we have been, on this
occasion, able to collect for observation or reasoning
in regard to the question considered by this essay, we
may now sum up the conclusions which we believe may be
legitimately derived from its analysis. These conclusions
may be best summarized in the form of answers to the ques-
tions propounded on pp. 193-194.

I. When pain exists from the first menstruation it de-
pends upon : {a) Imperfect power of resistance in the nerve
centres, which renders them unduly susceptible to the excite-
ment of the increased vascular tension that prepares the men-
strual flow. This excitement may be in itself a cause of gen-
eral disturbance, or be followed by exhaustion, which is
necessarily accompanied by vaso motor irritation, hence local
disturbance in the circulation of the uterine walls, and conse-
quent atonic contractions of its fibre, {b) Disproportion
between the development of the uterus and that of the rest
of the body, resulting in various organic defects of the genital
canal. The proximate cause of such disproportion, in the
actual state of science, often escapes us. But in a certain
class of cases, there is reason to accuse a precocious comple-
tion of development of the central nervous organs, especially
those of the cranial cavity,* and an equally precocious dim-
inution of muscular activity. On both accounts the moment
is earlv attained at which the muscles assume the habit of
rejecting a certain proportion of nutriment, in order to

* We follow Brown-Sequard in using this expression instead of the collective
term brain.

224 THE QUESTION OF REST FOR WOMEN.

provide for the development of the supplemental wave.
Individual nutrition is arrested, reproductive nutrition
commences before the organs of the individual have
been properly elaborated, and before the organs of repro-
duction have been sufficiently developed. Hence a double
cause of disorder and suffering, whose frequence is in
direct proportion to the prevalence of habits of luxury and
of purely ornamental education.* (r) Menstrual pain on the
contrary is acquired cither by the acquisition of the states of
imperfect nutrition, which in the first cases are congenital or
developed during childhood ; or by the continual aggravation
of the effects of the local organic imperfections, whose influ-
ence was at first slight ; or finally in consequence of organic
utero ovarian disease. The first and third cases may result
from various accidents common to the genesis of any disease
in either sex ; but also from two causes, very much more
frequently operative in women than men, namely, ill-arranged
work and celibacy ; finally from a third class of causes,
necessarily peculiar to women, sudden suppression of men-
strual hemorrhage, or the accidents of pregnancy and parturi-
tion. These last again are not in equal relation to all forms
of menstrual pain, or uterine disorder that may have existed
before marriage ; their liability is very much increased, in
any case where the contractility of uterine fibre has become
deficient or exhausted during repeated menstruations. It is
true, therefore, to say, that in certain cases, prolonged celi-
bacy or sterility, has been the real cause of the accidents of
parturition, and that the physiological necessity for repro-
duction, existing to a greater or less extent in all women, is
very much more imperious and earlier imposed in some
women than in others.'

^ All authors agree on the evils of premature menstruation, but we have not
seen these connected in the above manner with the genesis of neurotic disorder,
and of organic uterine disease.

* It is infinitely probable that the time at which this necessity is first felt by
the organism (if wc may so speak) is very much modified, as are all circumstances

CAUSES OF MENSTRUAL PAIN. 225

2. When persons in good health suffer severe menstrual
pain, this is nearly always dependent upon some anatomical
imperfection of the uterus. Like many other congenital im-
perfections, this may originally appear a mere trifle in the
sum of organic development, yet from the peculiar circum-
stances of the case, its results may assume gigantic pro-
portions.

When persons in delicate health are free from menstrual
distress, it is because the supplemental wave of nutrition
does not rise sufficiently to greatly increase general vascular
tension, or because the uterus is too slightly hyperaemiated
to excite reaction. We believe we have observed, though as
yet have no statistics to prove it, that the chlorotic or con-
sumptive girls who have suffered pain before marriage, sus-
tain their first pregnancy better, or are even improved by it
more, than those in whom, with equally low individual nutri-
tion, the supplemental wave had been too defective to cause
irritation.

3. That 46 per cent, of the women we have examined ty"
suffer more or less disturbance at menstruation, is a fact cer-
tainly connected with the habits of civilized life and the very
slender provision made for the physical education of girls,
especially for the development of their muscular nutrition.

No anatomical or physiological condition revealed to us by
the impartial analysis of the series of phenomena constituting
the entire menstrual process, is necessarily productive of
suffering. On the contrary, we discover in these rhythmic
waves of nutrition, as in the larger waves of gestation, re-
markable provisions for rhythmically (we cannot say period-
ically) increasing nutrition and the vital energy of the
woman. These provisions should serve to compensate for
the deficiency in the stimulus afforded by muscular activity.

of reproduction, by the social medium. For the age of marriage is constantly
receding, or at all events, marriages formerly called "late " are becoming more
and more frequent.

226 THE QUESTION OF REST FOR WOMEN.

The social perversions, by which these processes so often
deteriorate what they are naturally adapted to improve, are :
Bad physical education during childhood and adolescence;'
absence of employment, or work that is either absolutely
excessive or excessive relative to woman's constitution, by
being prolonged too much during a single session, or else
which is insufficiently relieved by recreation or insufficiently
spurred by interest ; unduly prolonged celibacy, and unequal
distribution of reproduction, on account of which many
women are broken down by excessive child-bearing, while
many others never obtain the opportunity to bear a single
child, for which, nevertheless, every fibre of their physical
and moral being is yearning.

4. The danger of disregarding menstrual pain when it
exists, varies with its proximate causes. Purely spasmodic
pain of moderate intensity, may be, and certainly is, tolerated
in an immense majority of cases, far better while the ordinary
occupations are continued. The tables show this. Pain
from organic defect, or from local nutritive disorder (conges-
tion, inflammation), should, wherever it be possible, claim
rest ; but this will not cure the pain, unless special treatment
be instituted. The only cases where rest really cures or pre-
vents menstrual pain, are those where general debility is so
marked that the loss of blood at menstruation is sufficient to
lower the nutrition of the nerve centres below the level to
which they are capable of generating force with ease. In
such case, any expenditure of force weakens them still fur-
ther, and vaso motor irritation and uterine cramps are the
result. Such persons may feel perfectly comfortable during
the menstrual flow, while inactive, but excitement or exertion
of body or mind brings on pain. In them the supplemental
wave of nutrition has been insufficient, yet the hemorrhage,

Mt is curious to notice how the effects of misery, and the effects of luAUry,
during the childhood of a girl, are found so often to result in an identical mode
of stunted development in adolescence.

DANGER OF MENSTRUAL PAIN. 22/

once commenced, is continued by habit and relaxation of
tissues ; the deficiency is supplied from the blood needed for
the individual nutrition.

5. The fifth question is answered by all that precedes,
and especially by the last paragraph. There is nothing in the
nature of menstruation to imply the necessity^ or even the
desirability y of resty for women whose nutrition is really
normal. The habit of periodical rest, in them, might indeed
easily become injurious, because in the cessation of nervo
muscular activity, the blood properly attracted to the mus-
cles and nerve centres would be diverted from them, and
tend towards the pelvis, increasing its hyperaemia above the
physiological standard. Many cases of pelvic congestion,
developed in healthy but indolent and luxurious women, are
often due to no other cause.

The reasoning which would attempt to show the existence
during the menstrual flow of a cerebro-spinal excitement,
determined by " ovarian irritation," incompatible with cerebro-
spinal activity, is entirely fallacious, and based on false anal-
ogies, especially with those of the rut. The menstrual flow
is the least important part of the menstrual process, and
arguments for rest drawn from the complexity of the physi-
ological phenomena involved in this, should logically demand
rest for women during at least twenty days out of the twenty-
eight or thirty. In other words, should consign them to the
inactivity of a Turkish harem, where indeed, anemia, if not
dysmenorrhea is said to be extremely frequent.

In the line of thought pursued throughout this essay, the
writer has held in view the demands for exertion made by
industrial labor, or by any such employments, as clerkships, or
teaching in average schools, as cannot be considered to in-
volve any decided mental labor. Indeed, if the question pro-
posed by the committee be regarded merely from the point
of view of the statistics of the census, we might be sur-
prised that the clause relating to mental rest had been

228 THE QUESTION OF REST FOR WOMEN.

inserted. This clause is evidently intended to cover the
position of women in school or college, in the professions,
finally in any pursuit of independent responsibility, where at
any moment may be required the exertion of independent
judgment, thought, and will. The clause may indeed be
intended to meet either negatively or affirmatively, a rather
widely diffused sentiment in regard to women's capacity for
such independent responsibilities. The habitual modesty of
American speech often enforces silence in regard to the fact
upon which this sentiment is supposed to be based, but from
time to time the silence is broken, and it is plumply asserted,
that ** during the temporary insanity of menstruation,** *
female judgment is unreliable, even unsafe, because no form
of mental action can be adequately carried on at this time.
It must follow, therefore, that no duties as thuse of law or
medicine for instance, for whose fulfillment the woman is
liable to be called upon during this critical period, should
ever be assumed by her. Justice to the public, if not to her-
self, demands that she should be peremptorily excluded from
such responsible fields of action, even when her own ill-starred
ambition may lead her to invade them. Among all the facts
we have examined, there is but one group that might seem to
justify the theory, that mental vest was imperative for women
in menstruation, whatever might be the case with physical.
We have seen that alterations of pressure exerted in the brain,
by varying degrees of vascular tension, may cause the most
extraordinary alterations in its functional activity and capa-
city for function, and a cardinal point in this essay has been
the attempt to show that in women exist certain fixed altera-
tions of vascular tension, over and above those common to
the physiological processes of the two sexes. But; ist.
These alterations succeed each other so gradually that the
brain sustains no shock for them, 2d. The rise in tension,
which presumably should affect the brain, does not occur

* See our former quotations.

NERVOUS PHENOMENA OF MENSTRUATION. 229

during the menstrual hemorrhage, which is the single period
covered by the question of the committee. 3d. Granted that
the brain is stimulated by increased vascular tension, it is
certain that when any habit of susceptibility has once been
established, it counts in the ordinary working of the organ.
4th. The reactions of the brain to alterations of blood
pressure are proportionate not only to them, but to the
degree of resistance of its own tissues. Our statistics show
that 53 per cent, out of two hundred and sixty-three women
interrogated at hazard, exhibit such a degree of resistance in
their nerve tissues as to enable them to bear with impunity
the increased vascular tension of the premenstrual week. It
is equally certain, however, that the reverse holds in a large
number of cases, though by no means in the 46 per cent, of
our tables. It is when the nutrition, and hence the vital
resistance of the nerve centres has been diminished, that the
rise in tension irritates nerve elements, and all degrees of
nervous erethism may be produced, from ill temper to in-
sanity. Berthier* (already referred to) has collected a large
number of cases where the approach of menstruation was
heralded by various forms of neurotic disorders — excitement,
epilepsy, hysteria, mania. But his list is burdened with
many cases, quite irrelevant, where the outbreak of the ner-
vous disease coincided with a suppression of menstruation,
and hence was due, either to the abrupt pathological increase
of vascular tension (where the suppression was sudden), or to
the same disorder of nutrition as had caused the amenorrhea
(in gradual cases). Similarly, all treatises on nervous or
mental disorders are crowded with cases showing that the
menstrual periods are frequently preceded by exacerbations
of the disease. We have, however, deemed it quite unneces-
sary for our purpose to pass these cases in review. How-
ever numerous, or however fantastic or various in character,
they all serve to illustrate only one fact, namely, that, when

* Neuroses Menstruelles.

230 THE QUESTION OF REST FOR -WOMEN.

the nutrition of the brain centres is weakened, increase of
blood pressure will cause various degrees of irritation of the
elements of which their tissues are composed. These patho-
logical causes are of no value for our purpose, except as
indicating the rhythmic increase of vascular tension upon
which w^c have insisted ; and they do not in the least show
that menstruation, per sCy constitutes any temporary pre-
disposition to either hysteria or insanity. 5. The real pre-
disposition to all the grand neuroses lies, not in the peri-
pheric conditions that may become exciting causes of their
development, but in the original structure of the central ner-
vous organs, without which these peripheric irritations could
have no effect. From what we have said of the peculiar
mode of nutrition that obtains in the female economy, it
becomes evident why women are so very much more fre-
quently hysterical. If the physiological denutrition of the
muscles be extended to the nerve centres, we have the atonic
hysteria of towns; if the supplemental wave of nutrition be
formed at the expense of the nerve centres instead of the
muscles, we have the muscular hysteria of peasants. It is
indeed primarily owing to the necessities of reproductive
nutrition that women are more liable to hysteria, and to
anemia than men. But until the anatomical basis of these
diseases shall have been raised, the " reproductive demand "
can only be considered a " cause " of them, in the same sense
in which birth may be said to caus6 death. In a word, when-
ever women exhibit mental irritability and consequent weak-
ness, at or before menstruation, it is a proof that the resist-
ance of their nerve centres is weakened below the normal
standard, sometimes congenitally and by inheritance. If the
impairment be sufficiently extensive, mental action will be
rendered unreliable, and the woman be subjected, therefore,
to periods of temporary incapacity, of varying degrees. In
certain such cases, the attempt to force mental action would
interfere still further with the nutrition of nerve tissues, and

RESISTANCE OF NERVE CENTRES IN WOMEN. 23 1

hence aggravate the original difficulty. In these cases rest is
desirable daring whatever period of the month the nervous ex-
citement may be experienced ; but this will be more frequently
through the two or three days preceding the hemorrhage,
than at the time of the flow. In slighter cases, rest is un-
necessary ; in those more severe, it is in itself useless, i. e.^
other measures must be taken in order to cure the disease.
In those cases of congenital hysteria where a cure cannot be
effected, it is evident that the women are permanently unfit
to bear severe responsibilities, or to undergo mental strain.
Of their mental action it must be said, as we have said in
regard to muscular action in weak subjects, that at any time
it tends to exhaust the small reserve of force accumulated
by the feeble nutritive capacity of the tissues. Thus, if
beyond the individual capacity at an intermenstrual period,
it will inflict an injury that cannot be repaired by rest during
menstruation.

In regard to women other than those considered in the
above classes, we can find no reason to suppose that men-
strual rest is desirable or necessary. Wherever it is so, it
will be taken, i, e,y no really mental work will ever be per-
formed at a time that the brain is really unable to perform it.
Whatever is done at such times, should be classed with work
involving muscular effort and the strain of fixed attention.
It is, therefore, only in regard to school girls and young per-
sons, called upon to perform mental work to order, {i. e, with-
out spontaneity) that the question really practically applies.
To these must be applied all that has been said in the fore-
going paragraph, with one addition, that in adolescence,
and during the first years that the reproductive wave of nu-
trition is being formed, mental work exacted in excess of the
capacity of the individual^ may seriously derange the nutri-
tion. In grading the work therefore, it must be proportioned ;
1st. To the conscious ease with which it can be performed.
2d. To the duration of the separate sessions of study. 3d.

232 CONCLUSION.

To the known standard of nutrition of the nerve centres, in
the individual case, especially as measured by predisposition
to hysteria, chorea, insanity or consumption. 4th. To the
coincident maintenance of proper hygienic conditions, es-
pecially in regard to food, air and exercise. The regulations
for menstruation, as said, to be entirely individual, and in
accordance with what has been detailed in speaking of the
mental work of adult women.

Any modifications which may be demanded in female labor
(modifications unnecessary in multitudes of individual cases,
but desirable for the mass) are in relation, not with the men-
strual flow, nor with " nervous excitability " which may be
occasioned by it in pathological cases, but with the nutritive
provision for reproduction, of which the flow is only one in-
dication. // is to the development of a supplemental wave of
nutrition^ and the manner in which it intersects the waves of
individual niitrition, that are due most of the peculiarities of
the female organism and of its activity, and not the mere
existence of reproductive organs. For theoretical reasons
exposed in detail, and from the results of observation, we are
authorized in asserting that women do work better, and with
much greater safety to health when their work is frequently
intermitted ; but that those intermittences should be at short
intervals and lasting a short time, not at long intervals and
lasting longer.

Finally, that they are required at all times, and have no
special reference to the period of the menstrual flow.

It remains true, however, that in our existing social con-
ditions, 46 per cent, of women suffer more or less at menstru-
ation, and for a large number of these when engaged in
industrial pursuits or others, under the command of an em-
ployer, humanity dictates that rest from work during the
period of pain be afforded whenever practicable.

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